Get Nv Fa-59 2017-2025

The NV FA-59 form is essential for healthcare providers requesting prior authorization for medications covered under Nevada Medicaid. This guide provides clear, step-by-step instructions to ensure you fill it out correctly and efficiently.

Follow the steps to complete the NV FA-59 form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the date of request at the top of the form. This should be the current date when you are submitting the authorization request.
3. In the recipient information section, fill in the last name, first name, and middle initial of the person who will be receiving the medication. Additionally, provide their recipient ID.
4. Next, input the date of birth and gender of the patient. Select either 'male' or 'female' accordingly and provide a contact phone number.
5. Move to the prescribing provider information section. Here, include the name, NPI (National Provider Identifier), phone number, and fax number of the prescribing physician. Also, name a person who can be contacted regarding this request.
6. Fill out the requested drug section. Provide the name of the drug, its strength, dosage, and duration of treatment. Note that generic substitution is not permitted.
7. In the previous therapy section, document any previous medications related to this request, including their name, strength, dosage, and duration.
8. In the clinical information section, include the diagnosis along with the ICD-10 code, if applicable. Write down any diagnostic procedures and findings, including their respective dates.
9. Provide a medical justification for the product's use, ensuring you explain why the requested drug is necessary.
10. Finally, the provider certification section must contain the prescriber’s signature and date. Confirm that the treatment is indicated and necessary based on Nevada Medicaid guidelines.
11. After completing the form, review all provided information for accuracy. Save changes, and proceed to download, print, or share the completed form as needed.

Complete your documents online efficiently by following these steps.