Follow the steps to successfully complete the NV FA-19 form.

1. Press the 'Get Form' button to access the NV FA-19 and open it in the editing interface.
2. Begin by selecting the appropriate screening type and reason for screening. Ensure that you choose only one option from the list provided.
3. Enter the date of the assessment and select the applicable service level, ensuring to check the relevant categories such as initial placement or standard.
4. Fill out the requesting facility or provider information. This includes entering your last name, first name, telephone number, organization ID, organization name, fax number, and the organization’s address details.
5. Provide the recipient information. Input the recipient’s last name, first name, middle name, permanent mailing address, city, street address, state, and zip code.
6. Complete the personal details section, including the recipient's social security number, date of birth, home or cell number, Medicaid ID number, Medicaid status, and county of residence.
7. Document the medical history by entering current diagnoses. If there are other relevant diagnoses, please specify.
8. List the recipient’s current medications and confirm whether they can safely self-administer medications.
9. Indicate any special needs by checking the applicable options and providing details about the frequency and specifics of the treatments if required.
10. Assess the activities of daily living (ADLs) by selecting appropriate options for each category, indicating the level of assistance required.
11. For instrumental activities of daily living (IADLs), document the recipient's performance level for each activity.
12. Select any additional areas where the recipient may need supervision.
13. Finally, the screener must provide their signature and title at the bottom of the form to certify the completion of the assessment.
14. Once all sections are filled out, save your changes, then you may download, print, or share the completed form as needed.

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