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The Nevada FA 27 form is an essential document for hospice agencies operating within the state. It serves as a notification tool for HP Enterprise Services, specifically regarding the enrollment, changes, or recertification of hospice recipients. Timeliness is crucial; agencies must submit this form within 72 hours of any new or updated information. To ensure a complete submission, several attachments are required, including a certificate of terminal illness, an election of hospice services, and updated physician orders. If the recipient is in a nursing facility, additional documents like a PASRR screening and LOC Determination Letter must accompany the FA 27 form. This comprehensive approach helps maintain accurate records and ensures that recipients receive the appropriate care. The form also collects vital information about the hospice agency, attending physician, and the recipient, including their medical history and current services. For any questions or clarifications, agencies can reach out to a dedicated support line. Proper completion and timely submission of the FA 27 form are crucial steps in facilitating effective hospice care in Nevada.

Nevada Fa 27 Sample

HP Enterprise Services - Nevada Medicaid and Nevada Check Up

Hospice Notification Form

Purpose: For a hospice agency to notify HP Enterprise Services of any hospice recipient enrollment, GLVFKDUJH change or recertification. Fax this form to HP Enterprise Services within 72 hours of new or FKDQJHG LQIRUPDWLRQ

Attachments: These attachments must be submitted with this form: 1) certificate of terminal illness,

2)election of hospice services and 3) updated physician orders for recertification. If the recipient is residing or will reside in a Nursing Facility, a PASRR screening and LOC Determination Letter must be attached in addition to the documents listed above.

Fax this form to: (866) 480-9903

For questions regarding this form, call:

(800) 525-2395

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUBMISSION DATE (date this form is submitted):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HOSPICE AGENCY INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

 

NPI:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone:

 

 

 

 

 

 

 

 

 

Fax:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHYSICIAN INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attending Provider Name:

 

 

 

 

 

 

 

 

NPI:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hospice Physician Name:

 

 

 

 

 

 

 

 

NPI:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RECIPIENT INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Recipient Name (last, first, MI):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address (include city, state and zip):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Recipient ID:

 

 

 

 

 

 

 

 

 

Medicare ID (if applicable):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth:

 

 

 

 

 

 

 

 

 

Sex:

Male

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone:

 

 

 

 

 

Marital Status:

 

Single

Married

Divorced

Widowed

 

List the names of all of all other payors (if

 

applicable):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTIFICATIONS AND CLINICAL INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hospice Diagnosis:

 

 

 

 

 

 

 

 

 

ICD-9 Code(s):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hospice Enrollment Date:

 

 

 

 

 

 

Recertification Date:

 

 

 

Certification Period:

1st 90 days

2nd 90 days

 

 

60 days

 

 

 

 

 

 

 

 

 

 

Revocation Date (hospice disenrollment):

 

 

 

 

 

 

 

Transfer Date to New Facility:

 

 

 

 

 

 

 

 

 

 

 

Date of Discharge to Home, on Hospice:

 

 

 

 

 

 

 

Date of Death:

 

 

 

 

 

 

 

 

 

Is the recipient currently residing in a Nursing Facility?

 

 

No

Yes – If yes, complete next section.

 

 

 

 

 

 

Other Services Currently Provided:

Personal Care Services (PCS)

Waiver Services

None

 

If PCS or waiver services are being provided, you must submit a completed Form FA-24A, "Care Coordination

 

for Hospice and PCS or Waiver Services."

 

 

 

 

 

 

 

 

 

 

 

 

NURSING FACILITY INFORMATION (Required if recipient currently resides in a Nursing Facility.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

 

NPI:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone:

 

 

 

 

 

 

 

 

 

Fax:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is the recipient residing in a Medicaid bed?

No

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUBMITTER INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Person Completing this Form:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

Phone:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FA-27

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File Attributes

Fact Name Fact Description
Purpose The Nevada FA 27 form is used by hospice agencies to notify HP Enterprise Services about enrollment, changes, or recertification of hospice recipients.
Submission Deadline This form must be faxed to HP Enterprise Services within 72 hours of new or changed information.
Required Attachments Three documents must accompany the FA 27 form: a certificate of terminal illness, an election of hospice services, and updated physician orders for recertification.
Nursing Facility Requirement If the recipient resides in a Nursing Facility, a PASRR screening and LOC Determination Letter must also be attached.
Fax Number The completed form should be faxed to (866) 480-9903.
Contact for Questions For inquiries regarding the FA 27 form, individuals can call (800) 525-2395.
Governing Law The use and requirements for the FA 27 form are governed by Nevada state law regarding Medicaid and hospice services.
Recipient Information The form collects detailed information about the hospice recipient, including their name, address, and Medicare ID, if applicable.
Clinical Information Hospice diagnosis and relevant codes, as well as enrollment and recertification dates, are documented on the form.
Signature Requirement The form must be signed by the person completing it, along with the date and their phone number.
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