Prior Authorization / Intensive In-Home Treatment Attachment Form
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1
2DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
DHS 107.22(4), Wis. Admin. Code
F-11036 (07/12)
FORWARDHEALTH
PRIOR AUTHORIZATION / INTENSIVE IN-HOME TREATMENT ATTACHMENT (PA/ITA)
Instructions: Type or print clearly. Before completing this form, read the Prior Authorization/Intensive In-Home Treatment Attachment
(PA/ITA) Completion Instructions, F-11036A. Providers may submit prior authorization (PA) requests to ForwardHealth by fax at
(608) 221-8616 or by mail to: ForwardHealth, Prior Authorization, Suite 88, 313 Blettner Boulevard, Madison, WI 53784.
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’s National Provider Identifier
6. Telephone Number — Rendering Provider
7. Credentials — Rendering Provider
SECTION III — SERVICE REQUEST
Initial Authorization Second Authorization
Third Authorization
Fourth Authorization
8. CHECK ONE
9. Enter the requested start and end dates for this authorization request. If backdating is needed for the initial PA request, it must be
requested in writing, and the clinical rationale for starting services before authorization is obtained must be documented.
10. Enter the name and credentials of the second team member. Include his or her degree and the number of hours of supervised
clinical work he or she has done with severe emotional disturbance (SED) children in the space provided (attach résumé, if
available).
11. Enter the pattern and frequency of treatment planned over this PA grant period.
Certified Psychotherapist/Substance Abuse Counselor — ALONE
Individual Sessions:
hours per session;
sessions per week.
Family Sessions:
hours per session;
sessions per week.
Certified Psychotherapist / Substance Abuse Counselor and Second Team Member — TOGETHER
Individual Sessions:
hours per session;
sessions per week.
Family Sessions:
hours per session;
sessions per week.
Second Team Member — ALONE
Individual Sessions:
hours per session;
sessions per week.
Family Sessions:
hours per session;
sessions per week.
12. Enter the travel time requested for this PA grant period. (The maximum allowable quantity of travel time is the time actually
required for travel from either the office and home, or the previous appointment and home, whichever is less.)
Certified Psychotherapist / Substance Abuse Counselor
Second Team Member
Total Number of Visits:
Total Number of Visits:
Travel Time per Visit
x
Hours
Travel Time per Visit
x
Hours
Total Travel Time
=
Hours
Total Travel Time
=
Hours
Continued
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