Crisis Intervention Services - Nevada Medicaid and Nevada Check - medicaid nv 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the DATE OF REQUEST in the designated fields. Ensure the date is accurate as it is crucial for processing.
3. Fill in the RECIPIENT INFORMATION section, including Recipient Name, Recipient ID, and Date of Birth. This information identifies the individual receiving services.
4. In the PROVIDER INFORMATION section, input details such as Provider Name, NPI, Fax, and Phone. Make sure that the provider is a Qualified Mental Health Professional (QMHP).
5. Complete the SERVICE DETAIL AND DIAGNOSIS CODE section by entering Axis I Primary Code and providing a narrative that describes the recipient's behavior necessitating intervention.
6. Specify the level of risk and describe services provided in detail to ensure clarity for authorization purposes.
7. In the SERVICE REQUESTED section, list codes, modifiers, dates of service provided, units per day, days per week, and total units for each service requested.
8. Finally, have the provider sign and date at the bottom of the form before submitting it via fax to ensure compliance with submission guidelines.

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