NV · guidance
Nev. Medicaid Provider Type 64 (Hospice) Billing Guide, Hospice Forms
Hospice Forms
All fields on the forms are required to be filled in and, if specified, the physician signature must be included. Nevada
Medicaid Hospice forms requiring a physician signature, submitted without the physician signature. will not be accepted.
• Plan of Care (POC)
• FA-91 Hospice Program Action Form - to be completed for hospice discharge, change of hospice provider or
revocation of hospice services
• FA-92 Hospice Program Election Notice – Adults (aged 21 and over)
• FA-93 Hospice Program Election Notice – Pediatrics (under age 21)
• FA-94 Hospice Program Physician Certification of Terminal Illness
• FA-95 Hospice Prior Authorization Request
• FA-96 Hospice Extended Care Physician Review Form; required after recipient has been on hospice services for 12
months (aged 21 and over)
These forms are available under “Hospice Forms” on the Providers Forms webpage.
Provenance
- Source
- www.medicaid.nv.gov
- Retrieved
- 2026-10-02
- Edition
- nv-pt64-2026-07-27
- Content hash
5f3a267a0f090cea0732f6331ff1313438a444b5e0993fb20e423bc7273fa906
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