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 (HHS-687) (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)
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)