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Prior Authorization / Mental Health Evaluation

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DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

Division of Health Care Access and Accountability

DHS 107.13, Wis. Admin. Code

F-11033 (07/12)

FORWARDHEALTH

PRIOR AUTHORIZATION / MENTAL HEALTH AND / OR SUBSTANCE ABUSE EVALUATION

ATTACHMENT (PA/EA)

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. Instructions: Type or print clearly. Before completing this form,

read the Prior Authorization/Mental Health and/or Substance Abuse Evaluation Attachment (PA/EA) Completion Instructions, F-11033A.

Failure to complete all elements could result in return or denial of PA requests.

SECTION I — MEMBER INFORMATION

1. Name — Member (Last, First, Middle Initial)

2. Date of Birth —

3. Member Identification Number

Member

SECTION II — PROVIDER INFORMATION

4. Name — Rendering Provider

5. Rendering Provider National Provider Identifier

6. Telephone Number — Rendering Provider

7. Discipline — Rendering Provider

SECTION III — DOCUMENTATION

8. Indicate the type of evaluation being requested and why this evaluation is needed. If this was a referral, indicate who made the

referral. Be specific as to how the member will benefit from this evaluation. (Do not include Central Nervous Assessments

[Current Procedural Terminology procedure codes 96101-96120] in this request.)

9. Indicate other evaluations the provider is aware of that have been conducted on this member in the past two years. Indicate why

the requested evaluation does not duplicate earlier evaluations.

10. SIGNATURE — Rendering Provider

11. Date Signed

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Prior Authorization / Mental Health Evaluation

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