Download Fhsc 18 Nevada Template Open Editor Now

Download Fhsc 18 Nevada Template

The Fhsc 18 Nevada form is a crucial document used for the Level I Identification Screening under the Nevada Medicaid and Nevada Check Up Programs. This form is designed to assess individuals for mental illness, mental retardation, and related conditions, ensuring they receive appropriate care and services. For those needing assistance, filling out the form accurately is essential; click the button below to get started.

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Fhsc 18 Nevada Example

 

 

 

 

 

 

 

 

 

Nevada Medicaid and Nevada Check Up Programs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Health Services Corporation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LEVEL I IDENTIFICATION SCREENING (for PASRR)

 

"CONFIDENTIAL"

 

 

 

 

 

 

 

 

 

 

 

PHONE: 1-800-525-2395

 

FAX:

1-866-480-9903

 

 

 

 

 

 

 

 

 

 

DATE SUBMITTED to FHSC:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INITIAL___ UPDATE___

 

 

 

 

 

 

 

 

 

 

 

**PLEASE TYPE OR PRINT**

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Name:

 

 

 

 

 

 

 

 

SS #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Address:

 

 

 

 

 

 

 

 

Medicaid Billing #:

 

 

 

 

 

 

Sex:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DOB:

 

 

 

Pmt. Source:

 

Marital Status:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Known Diagnoses: _____________________________________________

 

Original Admit Date:

 

 

 

Admit Date:

 

 

 

 

Legal Representative:

 

 

 

 

 

 

 

 

Admitting Facility:

 

 

 

 

 

 

 

 

 

 

 

Provider ID#:

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

Requesting Facility:

 

 

 

 

 

 

 

Contact Name:

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

Telephone:

 

 

 

 

 

Fax:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone:

 

 

 

 

 

 

 

Fax:

 

 

Patient's Current Location

Home

 

Acute In-Patient

 

ER

 

 

Requestor:

 

 

 

 

 

 

 

 

 

 

 

Acute ObservBed

 

NF____

Rehab Hosp/Unit___ Other_____

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION I: MENTAL ILLNESS (MI) SCREENING

3.B. Concentration/task limitations within past 6 months and due to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MI (exclude problems with medical basis):

 

 

 

 

 

 

1.A. Psychiatric Diagnoses

 

 

 

 

 

 

 

F

O

N Serious difficulty completing age related tasks.

 

 

Severe Anxiety/Panic Disorder

 

 

Psychotic disorder

 

F

O

N Serious loss of interest in things.

 

 

 

 

 

 

 

 

Bipolar Disorder

 

 

 

Somatoform disorder

 

F

O

N Serious difficulty maintaining concentration/attention.

 

 

Delusional Disorder

 

 

 

Schizophrenia

 

F

O

N Numerous errors in completing tasks which he/she

 

 

Schizoaffective disorder

 

 

Eating disorder (specify)

 

 

 

 

 

should be physically capable of accomplishing.

 

 

Major depression

 

 

 

 

 

 

 

F

O

N Requires assistance with tasks for which he/she

 

 

Personality disorder

(specify)

 

 

 

 

 

 

 

 

should be physically capable of accomplishing.

 

 

Other :

 

 

 

 

 

 

 

F

O

N Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Notes:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.B. Psychiatric Meds

 

 

Diagnosis/Purpose

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.C. Significant problems adapting to typical changes within past 6

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

months and due to MI (exclude problems with medical basis):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y

N

Requires mental health intervention due to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

increased symptoms.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FHSC USE ONLY: Meets diagnosis criteria for chronicity?

 

Y

N

Requires judicial intervention due to symptoms.

 

 

 

 

 

 

 

 

 

Y

 

 

N

 

 

 

 

Y

N

Symptoms have increased as a result of adaptation

2.A. Psychiatric treatment more intense than outpatient received in past 2 years: (MORE THAN ONCE)

 

 

 

difficulties.

 

 

 

 

 

 

 

 

 

 

 

 

inpatient psych. hosp.(dates)

 

 

 

 

 

Y

N

Serious agitation or withdrawal due to adaptation

 

 

 

 

 

 

partial hosp./day treatment(dates)

 

 

 

 

 

 

difficulties.

 

 

 

 

 

 

 

 

 

 

 

 

other(dates)

 

 

 

 

 

 

 

 

Y

N

Other

 

 

 

 

 

 

 

 

 

 

 

2.B. Intervention to prevent hospitalization: (give dates)

 

Notes:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

supportive living due to MI(dates)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

housing intervention due to MI(dates)

FHSC USE ONLY:

 

 

MI Decision:

 

 

 

 

 

 

legal intervention due to MI(dates)

 

 

 

Meets criteria for disability?

 

 

Meets criteria for SMI:

 

 

suicide attempt(dates)

 

 

 

 

 

 

Y

 

N

 

 

 

Y

 

N

 

 

 

 

 

 

other

 

 

 

 

 

 

SECTION II: MENTAL RETARDATION (MR) AND RELATED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FHSC USE ONLY: Meets criteria for duration?

 

 

 

 

 

CONDITIONS (RC) SCREENING

 

 

 

 

 

 

 

 

 

Y

 

 

N

 

 

 

1.A. MR diagnosis:

 

N

 

Y (specify)

 

 

 

 

 

 

3. Role limitations in past 6 months due to MI: (excluding medical problems)

B. Undiagnosed but suspected MR:

 

N

 

Y

 

 

N/A

Indicate: "F" Frequently, "O"

Occasionally, or "N" Never

C. History of receipt of MR services:

 

N

 

Y

 

 

 

 

3. A. Interpersonal Functioning (exclude problems w/medical basis)

 

(if yes, specify):

 

 

 

 

 

 

 

 

 

 

 

F O N

Altercations

F

O

N

Social isolation/avoidance

2. Occurrence before age 18:

 

 

N

Y

 

 

 

 

F O N

Evictions

F

O

N

Excessive irritability

 

(if yes, specify age):

 

 

 

 

 

 

 

 

 

 

F O N Fear of strangers

F

O

N

Easily upset/anxious

2.A. Related conditions which impair intellectual functioning or adaptive

F O N Suicidal talk

F

O

N

Hallucinations

 

behavior.

 

 

Blindness

 

Deafness

 

 

 

 

 

 

F O N Illogical comments

F O N

Serious communication

 

 

Cerebral Palsy

 

Autism

Epilepsy

 

 

 

 

F O N

Other

 

 

 

difficulties

 

 

Closed head injury

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F

O

N

Other

B. Substantial functional limitations in 3 or more of the following:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Self-care

 

Mobility

 

Learning

 

 

 

 

Notes:

 

 

 

 

 

 

 

 

 

 

 

 

Self-direction

 

Capability for independent living

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Understanding/use of language

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C. Was the condition manifested before age 22?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N

 

 

Y (specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FHSC USE ONLY: Meets criteria for MR/RC?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MR Decision:

 

 

Y

 

N

 

 

 

 

 

 

 

Name and Professional Title of Person Completing Form: ___________________________ Date Completed:

 

 

 

Page 1 of 2

FHSC-18

Aug-03

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STOP HERE IF NO INDICATORS OF MI, MR OR RC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nevada Medicaid and Check Up Program

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Health Services Corporation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LEVEL I IDENTIFICATION SCREENING (for PASRR)

 

"CONFIDENTIAL"

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STOP HERE - IF NO INDICATORS OF MI, MR OR RC

 

SECTION VI: OTHER CATEGORICAL DETERMINATIONS(non-limited)

 

 

 

 

OTHERWISE CONTINUE

 

 

 

 

IIF.

 

Terminal Illness: Physician has certified life expectancy of less

SECTION III: DEMENTIA

(complete for both MI & MR/RC)

 

 

 

than 6 months. (Submit copy of certification).

A. Does the individual have a primary diagnosis of Dementia or

 

IIG.

 

Severe Physical Illness limited to:

 

 

 

Alzheimer's Disease?

 

 

 

 

 

 

 

 

 

 

 

 

Coma, Ventilator Dependence, functioning at a brain stem level

 

 

 

Y

 

N (specify)

 

 

 

 

 

 

 

 

 

 

 

 

or a diagnosis of Parkinson's, Chronic Obstructive Pulmonary

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B. Does the individual have any other organic disorders?

 

 

 

 

 

 

Disease, Huntington's disease, Amyotrophic lateral sclerosis

 

 

 

Y

 

N (specify)

 

 

 

 

 

 

 

 

 

 

 

 

or congestive heart failure which result in a level of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C. Is there evidence of undiagnosed Dementia or other organic

 

 

 

impairment so severe that the individual could not be expected

mental disorders?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

to benefit from specialized services.

 

 

 

Y

N

disoriented to time

Y

N

disoriented to situation

 

 

 

 

 

 

 

 

 

 

 

Y

N disoriented to place

Y

N

pervasive, significant confusion

FHSC USE ONLY:

 

 

 

 

 

 

Y N severe ST memory

Y N paranoid ideation

 

 

 

 

Meets Other Categorical Determination criteria?

 

 

deficit

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y

 

N

 

 

 

 

 

D. Is there evidence of affective symptoms which might be confused

 

SECTION VII: REQUESTING PROVIDER TO COMPLETE

with Dementia?

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Information (required if indicators of MI, MR/RC):

Y

N

frequent tearfulness

Y

N

severe sleep disturbance

 

 

 

Legal representative's name and address:

Y

N

frequent anxiety

Y

N

severe appetite disturbance

 

 

 

 

 

 

 

 

 

 

 

E. Can the requstor provide any corroborative information to affirm that the

 

 

 

 

 

 

 

 

 

 

dementing condition exists and is the primary diagnosis?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dementia work-up

 

 

Thorough mental status exam

 

 

 

 

 

 

 

 

 

 

 

____ Medical/functional history prior to onset of dementia

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary physician's name and address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STOP - If Dementia is primary to MI.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTINUE - for all MR/RC or non-primary dementia with MI.

 

 

 

 

 

 

 

 

 

 

 

FHSC USE ONLY: Meets dementia criteria?

 

 

Y

 

 

N

 

 

 

 

 

 

 

 

 

 

 

SECTION IV: EXEMPTED HOSPITAL DISCHARGE (EHD)*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A. Does the individual meet all of the following criteria?

 

 

 

 

 

 

Additional supporting documentation is attached/submitted.

 

 

 

Admission to a NF directly from a hospital after receiving

 

 

 

Physician's certification stating a less than 30 day nursing facility

 

 

 

acute in-patient care at the hospital; and

 

 

 

 

 

 

stay is needed to justify EHD is attached/submiited.

 

 

 

Requires NF services for the condition he/she received care in

 

 

Physician's certification for a less than six (6) month life

 

 

 

the hospital; and

 

 

 

 

 

 

 

 

 

 

 

 

expectancy for terminal illness is attached/submitted.

 

 

 

The attending physician has certified prior to NF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

admission that the individual will require less than 30 days

 

Date Form Completed:

 

 

 

 

 

 

 

 

 

NF services. (Submit copy)

 

 

 

 

 

 

 

 

Name and Professional Title of Person Completing form:

* Individuals meeting all above criteria are exempt from PASRR II

 

 

 

 

 

 

 

 

 

 

 

screening for 30 days. The receiving facility must submit a Level I

FHSC OFFICE USE ONLY:

 

 

 

 

 

by the 25th day to request PASRR Level II, when it is apparent

 

SUMMARY and DETERMINATION

 

 

 

the stay will exceed 30 days.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FHSC USE ONLY:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has indicators of MI, MR/RC

 

 

No indicators of MI,

Meets EHD criteria?

 

Y

 

 

N

 

 

 

 

 

 

 

 

 

 

 

MR/RC

Limitation Date:

 

 

 

 

 

 

 

 

 

 

 

 

Level I Identification Determination:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PASRR LEVEL II CATEGORICAL DETERMINATIONS

 

 

 

IA - Exempted Hospital Discharge

 

 

 

SECTION V: Time-Limited* CATEGORICAL DETERMINATIONS

 

 

 

IA - Qualifies for Categorical Determination

IIE. The following categories indicate the individual requires NF services

 

 

IA - Requires PASRR Level II Individual Evaluation

and does not require specialized services for the time specified.

 

 

 

IB - Has Dementia, Alzheimer's, Organic Brain Syndrome

A. _____ Convalescent care from an acute physical illness which

 

 

 

IC - Not MI, MR/RC or Demented

 

 

 

 

required hospitalization and does not meet all criteria for an EHD.

 

 

 

 

 

 

 

 

 

 

B.

 

 

Emergency protective service situation for MI or MR/RC

 

PASRR Level II Categorical Determination:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

individual - placement in NF not to exceed 7 days.

 

 

 

 

 

 

PAS (applicant to NF)

 

 

RR (resident in NF)

C.

 

 

Delirium precludes the ability to accurately diagnose. Facility

 

 

 

 

 

 

 

 

 

 

 

must obtain PASRR Level II as soon as the delirium clears.

 

 

 

IIE - Time Limited Approval Limitation Date: ________

D.

 

 

Respite is needed for in-home caregivers to whom the MI,

 

 

 

IIF - Terminal Illness

 

 

 

 

 

 

MR/RC individual will return.

 

 

 

 

 

 

 

 

 

 

 

 

IIG - Severe Physical Illness

 

 

 

*If any of the above are checked, receiving facility must submit a

 

 

 

 

 

 

 

 

 

 

 

new Level I to request PASRR Level II ten (10) days prior to the

 

Referral Needed for PASRR Level II Individual Evaluation:

limitation date listed below for resident's whose stay is anticipated

 

 

Referred for MI

Date Referred:

 

 

to exceed that date.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Referred for MR/RC

Date Referred:

 

 

FHSC USE ONLY: Meets IIE Categorical Determination Criteria?

 

 

 

Dual Referral MI and MR/RC

Date:

A.

 

 

Y

 

N

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B.

Appropriate for NF

 

Y

 

 

N

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Limited to: ____________________

 

 

 

 

 

Date Completed

FHSC Reviewer's Name/Signature

Note: Limitations for Convalescent care = 45 days, Emergency Protective Services = 7 days,

 

 

 

 

 

 

 

 

 

 

Delirium = 30 days, and Respite = 30 days.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FHSC-18

 

Jul 2003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 2 of 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
Click for Fhsc 18 Nevada

Guide to Writing Fhsc 18 Nevada

Filling out the Fhsc 18 Nevada form requires attention to detail and accuracy. This form is essential for assessing eligibility for various health services. Follow these steps to complete the form correctly.

  1. Begin by typing or printing the Patient Name in the designated space.
  2. Enter the Social Security Number (SS #) of the patient.
  3. Fill in the Home Address of the patient.
  4. Input the Medicaid Billing Number.
  5. Specify the Sex of the patient.
  6. Provide the Date of Birth (DOB).
  7. Indicate the Payment Source.
  8. Select the Marital Status.
  9. List any Known Diagnoses in the provided space.
  10. Fill in the Original Admit Date and the Admit Date.
  11. Provide the name of the Legal Representative, if applicable.
  12. Enter the Admitting Facility name.
  13. Input the Provider ID #.
  14. Provide the Address of the admitting facility.
  15. Fill in the Requesting Facility name.
  16. List the Contact Name and their Address.
  17. Include the Telephone and Fax numbers for the contact person.
  18. Indicate the Patient's Current Location by selecting from the options provided (e.g., Home, Acute In-Patient, etc.).
  19. Complete SECTION I regarding Mental Illness screening, checking the appropriate boxes for each question.
  20. Continue through the subsequent sections, providing necessary information for Mental Retardation, Dementia, and any other relevant categories.
  21. At the end of the form, include the name and professional title of the person completing the form, along with the Date Completed.

Once you have filled out the form, review it for accuracy. Ensure that all required sections are completed. After that, submit the form to the appropriate office for processing. Keep a copy for your records, as it may be needed for future reference.

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Understanding Fhsc 18 Nevada

What is the purpose of the Fhsc 18 Nevada form?

The Fhsc 18 Nevada form is used for the Level I Identification Screening for individuals applying for services through Nevada Medicaid and the Nevada Check Up Programs. This form helps assess whether a person has indicators of mental illness, mental retardation, or related conditions, which may require further evaluation or specialized services.

Who needs to complete the Fhsc 18 form?

The form must be completed by a qualified individual, such as a healthcare provider or a legal representative, who is familiar with the patient's medical history and current condition. It is essential that the person filling out the form provides accurate and detailed information to ensure the proper assessment of the patient's needs.

What information is required on the Fhsc 18 form?

The form requires various details, including the patient's name, Social Security number, home address, Medicaid billing number, date of birth, and known diagnoses. Additionally, the form asks for information regarding the patient's current location, legal representative, admitting facility, and any psychiatric or medical history that may be relevant to the assessment.

What happens after the Fhsc 18 form is submitted?

Once the form is submitted, it will be reviewed by the First Health Services Corporation (FHSC). They will determine if the individual meets the criteria for mental illness, mental retardation, or related conditions. If further evaluation is needed, the FHSC will initiate the appropriate steps for a Level II assessment.

How is confidentiality maintained when using the Fhsc 18 form?

The Fhsc 18 form is marked "CONFIDENTIAL," which indicates that the information contained within it is sensitive and should be handled with care. All individuals involved in the processing of this form are required to adhere to privacy regulations to protect the patient’s personal and medical information.

Can the Fhsc 18 form be updated after submission?

Yes, the Fhsc 18 form can be updated. If there are changes in the patient's condition or additional information becomes available, an updated form can be submitted. It is crucial to indicate whether the submission is an initial or an update to ensure proper processing.

What should I do if I have questions about filling out the Fhsc 18 form?

If you have questions or need assistance while completing the Fhsc 18 form, you can contact the First Health Services Corporation at their designated phone number, 1-800-525-2395. They can provide guidance and clarify any uncertainties you may have regarding the form and its requirements.

Common mistakes

  1. Incomplete Information: One of the most common mistakes is failing to fill out all required fields. Ensure that every section, including the patient’s name, address, and Medicaid billing number, is completed. Missing information can delay processing.

  2. Illegible Handwriting: If the form is not typed, legibility is crucial. Handwriting that is difficult to read can lead to misunderstandings. Always print clearly or type the information to avoid confusion.

  3. Incorrect Dates: Providing inaccurate dates, such as the date of birth or admission date, can create complications. Double-check these dates to ensure they match the patient’s records.

  4. Omitting Signatures: Failing to sign the form or having the wrong person sign can invalidate the submission. Make sure that the individual completing the form and any required legal representatives have signed where necessary.

  5. Not Specifying Diagnoses: When listing known diagnoses, be specific. Vague descriptions can hinder proper assessment. Use clear and precise language to describe any mental health conditions.

  6. Ignoring Instructions: Each section may have specific instructions that need to be followed. Skipping these can lead to errors. Read all instructions carefully before completing the form to ensure compliance with requirements.

Document Data

Fact Name Description
Purpose of Form The FHSC 18 form is used for Level I Identification Screening for individuals applying for Nevada Medicaid and Nevada Check Up Programs.
Governing Law This form is governed by Nevada Revised Statutes (NRS) Chapter 422, which outlines the state's Medicaid program.
Confidentiality The form is labeled "CONFIDENTIAL" to ensure the privacy of the patient's information during the screening process.
Contact Information For inquiries, individuals can reach First Health Services Corporation at 1-800-525-2395 or send a fax to 1-866-480-9903.
Patient Information The form requires essential patient details, including name, Social Security number, address, and Medicaid billing number.
Sections Included The form consists of multiple sections, including Mental Illness (MI) Screening, Mental Retardation (MR) and Related Conditions (RC) Screening, and Dementia Screening.
Indicators of Need It identifies indicators of mental illness, mental retardation, or related conditions to determine the need for further evaluation or services.
Exempted Hospital Discharge Individuals meeting specific criteria may be exempt from PASRR Level II screening for up to 30 days after hospital discharge.
Completion Requirements The form must be completed by a qualified professional, who is required to sign and date the document upon completion.

Documents used along the form

The Fhsc 18 form is an essential document used in Nevada for identifying individuals who may require further evaluation for mental illness, mental retardation, or related conditions. Alongside this form, there are several other documents that are frequently utilized to ensure comprehensive care and compliance with regulations. Below are some of these important forms.

  • PASRR Level II Evaluation Form: This form is used for individuals who have been identified as needing a more in-depth assessment after the Level I screening. It helps determine if specialized services are necessary for those with serious mental illness or intellectual disabilities.
  • Medicaid Application Form: This form is required for individuals seeking Medicaid benefits. It collects personal and financial information to determine eligibility for healthcare services, which is crucial for those needing long-term care.
  • Horse Bill of Sale Form: To facilitate proper documentation during transactions, refer to our detailed Horse Bill of Sale guide for legal compliance and accurate transfers.
  • Physician's Certification for Terminal Illness: This document is essential when claiming a terminal illness status. It must be completed by a physician, certifying that a patient has a life expectancy of six months or less, which can impact their care options.
  • Exempted Hospital Discharge Documentation: This paperwork is necessary for individuals discharged from a hospital to a nursing facility. It ensures that they meet specific criteria to bypass certain evaluations for a limited time, facilitating a smoother transition to care.

Understanding these forms and their purposes can help streamline the process for individuals seeking assistance. Ensuring that all necessary documentation is completed accurately and submitted on time is vital for receiving the appropriate care and support.

Similar forms

The FHSC 18 Nevada form is an essential document used in the evaluation process for individuals seeking assistance through Nevada's Medicaid and Check Up Programs. Several other documents serve similar purposes in assessing eligibility and needs for healthcare services. Here’s a look at four such documents:

  • Form 3000: Medicaid Application - This form is used to apply for Medicaid benefits. Like the FHSC 18, it collects personal and medical information to determine eligibility for financial assistance in healthcare. Both forms aim to assess the individual's needs and circumstances to facilitate appropriate care.
  • Form 1010: Disability Determination Request - This document is utilized to assess whether an individual qualifies for disability benefits. Similar to the FHSC 18, it requires detailed information about the applicant's medical history and limitations, focusing on how these factors impact daily functioning.
  • Form 701: Mental Health Assessment - This assessment form evaluates an individual's mental health status and needs. It shares a common goal with the FHSC 18, as both documents aim to identify mental health conditions and the level of care required, ensuring that individuals receive the appropriate support.
  • Dirt Bike Bill of Sale: This essential document records the transfer of ownership of a dirt bike in New York, ensuring a transparent transaction and legal validation. For more information, visit legalpdf.org.
  • Form 2020: Long-Term Care Application - This form is specifically for those seeking long-term care services. Like the FHSC 18, it gathers comprehensive information about the individual's medical and personal background to determine the most suitable level of care needed for their situation.

Understanding these documents can help individuals navigate the healthcare system more effectively. Each form plays a crucial role in ensuring that people receive the support and services they need based on their unique circumstances.