Prior Authorization / Hearing Instrument And Audiological Services

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
DHS 106.03(4), Wis. Admin. Code
F-11021 (07/12)
FORWARDHEALTH
PRIOR AUTHORIZATION REQUEST / HEARING INSTRUMENT
AND AUDIOLOGICAL SERVICES (PA/HIAS2)
Providers may submit prior authorization (PA) requests with attachments 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/Hearing Instrument and Audiological Services (PA/HIAS2) Completion Instructions, F-11021A.
SECTION I — PROVIDER INFORMATION
1. Name — Provider
4. Address — Provider (Street, City, State, ZIP+4 Code)
2. National Provider Identifier
3. Telephone Number — Provider
SECTION II — MEMBER INFORMATION
5. Name — Member (Last, First, Middle Initial)
6. Date of Birth — Member
7. Member Identification Number
8. Gender — Member
9. Has the Member Ever Used a
Hearing Instrument?
Male
Female
Yes
No
10. Describe Prior Hearing Instrument Use
11. Testing Date
12. Test Reliability (Check One)
Good
Fair
Poor
SECTION III — DOCUMENTATION
13.
14. Pure Tone Audiogram — Frequency in Hertz (Hz)
Legend
125
250
500
1000
2000
4000
8000
-10
___
Air
Bone
0
___
Un-
Un-
Ear
Masked
Masked
NR
masked
masked
10
___
∆ − ∆
<
o - o
[
Right
20
___
−
>
x - x
]
Left
30
___
40
___
50
___
SPEECH AUDIOMETRY
R
L
SF
60
___
Threshold (SRT or SDT)
70
___
Word recognition in quiet
80
___
Word recognition in noise
90
___
Uncomfortable level (dB-HL)
100
___
Most comfortable level (dB-HL)
110
___
120
750
1500
3000
6000
15. Additional Audiometric Studies and Results, Pertinent Social Background, Other Relevant Information (Use an Attachment if Necessary)
16. Recommendations for a Hearing Instrument (use an attachment if necessary)
Ear (Check One)
Left
Right
Both
Ear Mold Style_________________ Hearing Aid Style________________
Describe Electroacoustic Specifications
Ear Mold
Left
Right
Both
Special Modifications
17. SIGNATURE — Requesting Provider
18. Name — Requesting Provider (Print)
19. Provider Type (Check One)
20. Date Signed
Audiologist
Hearing Instrument Specialist
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