Provider Forms

• NEW Claims Reconsideration Form (PDF)
• NEW Claims Appeal Form (PDF)
• Nevada Medicaid Hysterectomy Acknowledgement Form (PDF)
• Abortion Declaration (Incest) (PDF)
• Abortion Declaration (Rape) (PDF)
• Sterilization Consent Form - English (PDF)
• Sterilization Consent Form - English Large Print (PDF)
• Sterilization Consent Form - Spanish (PDF)
• Sterilization Consent Form - Spanish Large Print (PDF)
• Outpatient Medicaid Prior Authorization Form (PDF) 
  • Important Note:  All fields with an asterisk need to be filled out. Incomplete forms will not be processed.
• Inpatient Medicaid Prior Authorization Form (PDF)
• Critical Incident Report Form (PDF)

• Medicare Reconsideration Form (PDF)
• Outpatient Medicare Prior Authorization Form (PDF)
• Inpatient Medicare Prior Authorization Form (PDF)

• Hospital - Facility Provider Application (PDF)
• Ownership and Controls Disclosure Form (PDF)
• Practitioner Data Form(PDF)
  
• PDM Credentialing Checklist (PDF)
• W9 Form (PDF)
• NV Standard Credentialing Application (PDF)

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 (PDF)
• NV Behavioral Health (NBH) Mobile Assessment Authorization (PDF)
• Behavioral Health Addendum (PDF)
• Outpatient Prior Authorization Form (PDF)
• Inpatient Prior Authorization Form (PDF)