Get Nv Fh-17 2004-2025

The NV FH-17 form is essential for requesting a level of care assessment for nursing facilities in Nevada. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to complete the NV FH-17 form online.

1. Click ‘Get Form’ button to obtain the NV FH-17 form and open it in your preferred editing tool.
2. Fill out the date of request in the designated field at the top of the form. Ensure that the date is formatted correctly for clarity.
3. Select the reason for screening from the provided options such as standard, initial placement, or service level change by checking the appropriate box.
4. Enter the provider information, including the provider name, Medicaid number, address, and contact details of the individual completing the form.
5. In the recipient information section, fill out the recipient's last name, first name, middle initial, ID number, date of birth, social security number, and screening location by selecting from options like acute, nursing facility, or home.
6. Complete the medical history section by providing up to three diagnoses and their corresponding ICD-9 codes, along with any medications the recipient is currently taking.
7. Indicate whether the recipient can self-administer medications by checking 'Yes' or 'No' and noting any barriers if applicable.
8. Check all relevant special needs items and provide additional information for treatments if necessary in the specified section.
9. For activities of daily living (ADL), check all boxes that apply and add comments as needed to further clarify the recipient's needs.
10. Assess the recipient's need for supervision by indicating any behavior concerns present and checking the relevant boxes.
11. Complete the instrumental activities of daily living (IADL) section by detailing relevant needs such as meal preparation and homemaking services.
12. Review the entire form to ensure all information is complete and accurate. Once finalized, save your changes, download, print, or share the form as needed.

Begin filling out your NV FH-17 form online today to streamline the assessment process.