Prior Authorization / Adult Mental Health Day Treatment Attachment (Pa/amhdta)
Download a blank fillable Prior Authorization / Adult Mental Health Day Treatment Attachment (Pa/amhdta) in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Prior Authorization / Adult Mental Health Day Treatment Attachment (Pa/amhdta) with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
DHS 107.13(4), Wis. Admin. Code
F-11038 (07/12)
FORWARDHEALTH
PRIOR AUTHORIZATION / ADULT MENTAL HEALTH DAY TREATMENT ATTACHMENT
(PA/AMHDTA)
Providers may submit prior authorization (PA) requests 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/Adult Mental Health Day Treatment Attachment (PA/AMHDTA) Completion Instructions, F-11038A.
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 — Requesting / Rendering Provider
5. Requesting / Rendering Provider’s National Provider Identifier
6. Telephone Number — Requesting / Rendering Provider
(NPI)
SECTION III — DOCUMENTATION
7. Number of Hours per Week Requested
8. Estimated Final Treatment Date
9. Has the member had previous adult mental health day treatment at the provider’s facility or elsewhere?
Yes
No
Unknown
If “yes,” list dates and locations.
10. Evaluation(s) (Include date[s], tests used, and results.)
Continued
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business