Prior Authorization/health And Behavior Intervention Attachment Form

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
DHS 107.13(2), Wis. Admin. Code
F-11088 (07/12)
FORWARDHEALTH
PRIOR AUTHORIZATION / HEALTH AND BEHAVIOR INTERVENTION ATTACHMENT (PA/HBA)
Providers may submit the completed prior authorization (PA) request by fax to ForwardHealth 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/Health and Behavior Intervention Attachment (PA/HBA) Completion Instructions,
F-11088A.
SECTION I — MEMBER INFORMATION
1. Name — Member (Last, First, Middle Initial)
2. Date of Birth — Member
3. Member Identification Number
SECTION II — PROVIDER INFORMATION
4. Name — Rendering Provider
5. Rendering Provider National Provider Identifier
6. Telephone Number — Rendering Provider
7. Credentials — Rendering Provider
SECTION III — CLINICAL INFORMATION
8. Physical Health Diagnosis Related to the Need for Health and Behavior Interventions
9. Biopsychosocial Factors Related to the Member’s Physical Health Status
10. Treatment Modalities
11. Treatment Schedule
12. Member’s Measurable Goals of Treatment Modalities
13. Anticipated Duration of Treatment
14. SIGNATURE — Rendering Provider
15. Date Signed
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