Hospitals must report whenever a hospital admission, discharge or death of a Nevada Medicaid patient occurs.
Must be submitted within 72 hours of occurrence or notification of pending Medicaid status.
Submit Form 3058 to your local Division of Welfare and Supportive Services District Office:
Northern Offices: https://dwss.nv.gov/Contact/Welfare_District_Offices-North/
Southern Offices: https://dwss.nv.gov/Contact/Welfare_District_Offices-South/
Failure to submit this form could result in payment delay or denial.
F. Form 3058 (Admit/Discharge/Death Notice)
All hospitals are required to submit Form 3058 to their local Nevada Division of Welfare
and Supportive Services (DWSS) District Office whenever a hospital admission, discharge
or death occurs.