Prior Authorisation / Child / Adolescent Day Treatment Attachment
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5DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
DHS 107.22, Wis. Admin. Code
F-11040 (07/12)
FORWARDHEALTH
PRIOR AUTHORIZATION / CHILD / ADOLESCENT DAY TREATMENT ATTACHMENT
(PA/CADTA)
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/Child/Adolescent Day Treatment Attachment (PA/CADTA) Completion Instructions, F-11040A.
Initial Request
First Reauthorization
Second Reauthorization
Subsequent Reauthorization
SECTION I — MEMBER INFORMATION
1. Name — Member (Last, First, Middle Initial)
2. Age — Member
3. Member Identification Number
SECTION II — PROVIDER INFORMATION
4. Name — Day Treatment Provider
5. Day Treatment Provider's National Provider Identifier
6. Name — Contact Person
7. Telephone Number — Contact Person
SECTION III — DOCUMENTATION
8. Indicate the requested start date and end date for this authorization period. If the requested start date is earlier than the date the
prior authorization request form is first received by ForwardHealth, specifically request backdating and state clinical rationale for
starting services before PA is obtained.
9. Indicate the number of hours of treatment to be provided over the PA grant period. Indicate the pattern of treatment (e.g., three
hours per day, three days per week for eight weeks).
Continued
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