Prior Authorization

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
DHS 107.15(3), Wis. Admin. Code
F-11029 (07/12)
FORWARDHEALTH
PRIOR AUTHORIZATION / CHIROPRACTIC ATTACHMENT (PA/CA)
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/Chiropractic Attachment (PA/CA) Completion Instructions, F-11029A.
SECTION I — PROVIDER INFORMATION
1. Name — Provider
2. Address — Clinic or Office Where Service(s) Is Provided
3. National Provider Identifier
4. Telephone Number — Provider
SECTION II — MEMBER INFORMATION
5. Name — Member (Last, First, Middle Initial)
6. Date of Birth — Member
7. Member Identification Number
SECTION III — SERVICE INFORMATION
8. Total Number of Services Requested (Specify)
9. Total Number of Weeks Requested
10. Requested Start Date of Prior Authorization
SECTION IV — SUPPORTING INFORMATION
11. Date of Spell of Illness
12. Date of Beginning Treatment
13. History
a) Initial
b) Spell of Illness
c) Previous and / or Concurrent Care
Continued

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