Prior Authorization / Adult Mental Health Day Treatment Attachment (Pa/amhdta) Page 4
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4PRIOR AUTHORIZATION / ADULT MENTAL HEALTH DAY TREATMENT ATTACHMENT (PA/AMHDTA)
Page 4 of 4
F-11038 (07/12)
SECTION III — DOCUMENTATION (Continued)
I have read the attached requests for PA of adult mental health day treatment services and agree that it will be sent to
ForwardHealth for review.
19. SIGNATURE — Member or Representative
20. Date Signed
21. Relationship (If Representative)
22. SIGNATURE — Therapist Providing Treatment
23. Date Signed
24. SIGNATURE — 51.42 Board Director / Designee (no longer required)
25. Date Signed (no longer required)
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