Follow the steps to successfully complete the NV FA-1D form.

1. Click the ‘Get Form’ button to access the NV FA-1D and open it in your online editor.
2. Fill in the date of the request at the top of the form.
3. Provide the recipient information by entering the recipient's name, Medicaid ID, date of birth, and phone number.
4. Complete the provider information section, including the name of the durable medical equipment (DME) company, fax number, national provider identifier (NPI), and phone number.
5. In the wheelchair information section, input details about the wheelchair, including the make, model, and serial number.
6. Record the hour reading, the age of the equipment in months, and the initial dispense date.
7. Indicate who purchased the wheelchair and state whether it was purchased by Nevada Medicaid. If not, ensure the recipient meets current qualifications.
8. Answer whether the wheelchair is within the manufacturer’s warranty and provide a copy of warranty information if applicable.
9. Detail the initial complaint that prompted the repair evaluation and explain how the wheelchair came to be in disrepair.
10. Submit service repair documentation from the technician describing the evaluation process, including previous repairs and service dates.
11. Itemize all replacement parts and their costs, including any necessary unaltered complete order forms. Estimate labor costs as well.
12. In the certification section, read the statement carefully, then sign and print your name along with the signature date and phone number.
13. Once completed, save your changes, download, or print the form for submission according to the guidelines provided.

Complete your NV FA-1D form online today to ensure timely processing of your wheelchair repair request.