Manuals, Forms and Resources

Manuals and Forms

• Annual Care for Older Adults (COA) Form (PDF)
• Provider Medicaid Manual (PDF)
  
• Provider Medicare Manual - 2022 (PDF)
• Provider Medicare Manual (PDF)
• Provider Billing Manual (PDF)
• Required Reconsideration Dispute Form (PDF) 
• Nevada Medicaid Hysterectomy Acknowledgement Form (PDF)
• Abortion Declaration (Incest) (PDF)
• Abortion Declaration (Rape) (PDF)
• Sterilization Consent Form (HHS-687) (PDF)
• Notification of Pregnancy Form (PDF)
• Outpatient Medicaid Prior Authorization Form (PDF)
• Inpatient Medicaid Prior Authorization Form (PDF)
• Outpatient Medicare Prior Authorization Form (PDF)
• Inpatient Medicare Prior Authorization Form (PDF)

Credentialing and Contracting

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

• 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)

Other Resources

• Choosing Wisely Information on promoting conversations between patients and clinicians.