Form FA-174 Wakix (Pitolisant) Medications Prior Authorization Request Form - Nevada

Form FA-174 Wakix (Pitolisant) Medications Prior Authorization Request Form - Nevada

What Is Form FA-174?

This is a legal form that was released by the Nevada Department of Health and Human Services - a government authority operating within Nevada. As of today, no separate filing guidelines for the form are provided by the issuing department.

FAQ

Q: What is Form FA-174?
A: Form FA-174 is a Medications Prior Authorization Request Form.

Q: What is Wakix (Pitolisant)?
A: Wakix (Pitolisant) is a medication.

Q: What is the purpose of the Form FA-174?
A: The purpose of the Form FA-174 is to request prior authorization for Wakix (Pitolisant) medication.

Q: Who needs to fill out Form FA-174?
A: The form needs to be filled out by individuals who need to request prior authorization for Wakix (Pitolisant) medication.

Q: Is Form FA-174 specific to Nevada?
A: Yes, Form FA-174 is specific to Nevada.

Q: Are there any instructions for filling out Form FA-174?
A: Yes, instructions for filling out the form are typically provided along with the form.

Q: What other information may be required for the prior authorization request?
A: Other information that may be required includes medical records, diagnosis, and supporting documentation.

Q: Who should I contact if I have questions about Form FA-174?
A: You should contact the relevant healthcare provider or insurance company for assistance with Form FA-174.

Q: Are there any fees associated with submitting Form FA-174?
A: Fees may vary depending on the healthcare provider or insurance company, and it is best to check with them directly.

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Form Details:

  • Released on August 31, 2020;
  • The latest edition provided by the Nevada Department of Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form FA-174 by clicking the link below or browse more documents and templates provided by the Nevada Department of Health and Human Services.

Download Form FA-174 Wakix (Pitolisant) Medications Prior Authorization Request Form - Nevada

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