Prior Authorization / Home Health Therapy Attachment (Pa/hhta)

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
DHS 107.11(3), Wis. Admin. Code
F-11044 (07/12)
FORWARDHEALTH
PRIOR AUTHORIZATION / HOME HEALTH THERAPY ATTACHMENT (PA/HHTA)
Providers may submit prior authorization (PA) requests with attachments to ForwardHealth by fax at (608) 221-8616 or by mail to
ForwardHealth, Prior Authorization, Suite 88, 313 Blettner Boulevard, Madison, WI 53784. Instructions: Type or print clearly. Before
completing this form, read the Prior Authorization/Home Health Therapy Attachment (PA/HHTA) Completion Instructions, F-11044A.
SECTION I — MEMBER INFORMATION
1.
Name — Member (Last, First, Middle Initial)
2.
Age — Member
3.
Member Identification Number
SECTION II — PROVIDER INFORMATION
4.
Name and Credentials — Therapist
5.
Therapist’s National Provider Identifier (NPI)
6.
Telephone Number — Therapist
7.
Name — Referring / Prescribing Physician
8.
Referring / Prescribing Physician’s NPI
SECTION III — DOCUMENTATION
9.
Provide a brief history pertinent to the service(s) requested.
10. Provide a description of the member’s diagnosis and problems as they pertain to the need for the therapy services requested.
(Include the date of onset.)
Continued

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