Get Nv Fa-1d 2015

Filling out the NV FA-1D form online can streamline the process of submitting a wheelchair repair request. This guide will provide you with clear and detailed instructions to ensure that you complete the form accurately and efficiently.

Follow the steps to fill out the NV FA-1D form online.

1. Press the ‘Get Form’ button to obtain the NV FA-1D form and open it for editing.
2. Enter the date of request in the specified format (MM/DD/YYYY).
3. Complete the recipient information section, providing the recipient's name (last, first, middle initial), Medicaid ID, date of birth, and phone number.
4. Fill out the provider information by 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, provide details such as the make, model, and serial number of the wheelchair.
6. Document the hour reading and the age of the equipment in months, along with the initial dispense date.
7. Indicate whether the wheelchair is within the manufacturer’s warranty by checking 'Yes' or 'No.' If applicable, include a copy of the warranty information.
8. Record the name of the manufacturer of the replacement parts.
9. Describe the initial complaint that prompted the repair evaluation and explain how the wheelchair came to be in disrepair, detailing the usage schedule if normal wear and tear is the reason.
10. Provide service repair documentation from the technician, detailing the evaluation process and findings.
11. Itemize all replacement parts and their costs, and estimate the cost of labor.
12. In the certification section, sign and print your name, indicating the date of signature and providing your phone number.
13. Review the completed form for accuracy, then save any changes, and prepare to download, print, or share the form as required.

Complete your NV FA-1D form online today to ensure a smooth submission process.