Provider Forms
Forms Applicable for Medicaid, Ambetter and Medicare
Medicaid Forms
- Medicaid Reconsideration Dispute Form (PDF)
- Nevada Medicaid Hysterectomy Acknowledgement Form (PDF)
- Abortion Declaration (Incest) (PDF)
- Abortion Declaration (Rape) (PDF)
- Sterilization Consent Form (HHS-687) (PDF)
- Outpatient Medicaid Prior Authorization Form (PDF)
- Inpatient Medicaid Prior Authorization Form (PDF)
- Critical Incident Report Form (PDF)
Medicare Forms
- Medicare Reconsideration Form (PDF)
- Outpatient Medicare Prior Authorization Form (PDF)
- Inpatient Medicare Prior Authorization Form (PDF)
Credentialing and Contracting Forms
- Hospital - Facility Provider Application (PDF)
- Ownership and Controls Disclosure Form (PDF)
- Provider Data Form (PDF)
- PDM Credentialing Checklist (PDF)
- W9 Form (PDF)
- NV Standard Credentialing Application (PDF)
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
- Requests for IP, RTC, and PHP 1.22 (PDF)
- Completing an OTR: Tips, Pitfalls & Common Mistakes (PDF)
- Electroconvulsive Therapy (ECT) Form (PDF)
- Intensive Outpatient Form for Mental Health/Chemical Dependency (PDF)
- Inpatient and Outpatient Neuropsychological & Psychological Testing Form (PDF)
- Applied Behavioral Analysis (ABA) Authorization Request Form (PDF)
- Outpatient Treatment Request Form (PDF)
- Nonpar Outpatient Treatment Request Form (PDF)
- NV Behavioral Health (NBH) Mobile Assessment Authorization (PDF)
- Behavioral Health Addendum (PDF)