Manuals, Forms and Resources

Manuals and Forms

• Provider Manual
• Provider Billing Manual
• Nevada Medicaid Hysterectomy Acknowledgement Form
• Abortion Affidavit Form (Incest)
• Abortion Declaration (Incest)
• Abortion Affidavit Form (Rape)
• Abortion Declaration (Rape)
• Sterilization Consent Form
• Notification of Pregnancy Form
• Outpatient Medicaid Prior Authorization Form
• Inpatient Medicaid Prior Authorization Form

Credentialing and Contracting

• Hospital - Facility Provider Application
• Ownership and Controls Disclosure Form
• Provider Data Form 
• PDM Credentialing Checklist
• W9 Form

Behavioral Health Forms

For applicable service requests, please include the following clinical documentation: LOCUS/CASII Score and Intensity of Needs Level

Discharge Summaries should be faxed to 1-866-535-6974

• Completing an OTR: Tips, Pitfalls & Common Mistakes
• Electroconvulsive Therapy (ECT) Form
• Intensive Outpatient Form for Mental Health/Chemical Dependency
• Inpatient and Outpatient Neuropsychological & Psychological Testing Form
• Applied Behavioral Analysis (ABA) Authorization Request Form
• Outpatient Treatment Request Form
• Nonpar Outpatient Treatment Request Form
• NV Behavioral Health (NBH) Mobile Assessment Authorization
• Behavioral Health Addendum