Revocation Of Power Of Attorney For Health Care Wi
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4DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
DHS 107.13(3), Wis. Admin. Code
F-11032 (07/12)
FORWARDHEALTH
PRIOR AUTHORIZATION / SUBSTANCE ABUSE ATTACHMENT (PA/SAA)
Providers may submit prior authorization (PA) requests and 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/Substance Abuse Attachment (PA/SAA) Completion Instructions, F-11032A.
SECTION I — MEMBER INFORMATION
1. Name — Member (Last, First, Middle Initial)
2. Age — Member
3. Member Identification Number
SECTION II — PROVIDER INFORMATION
4. Name and Credentials — Rendering Provider
5. Rendering Provider’s National Provider Identifier (NPI)
6. Telephone Number — Rendering Provider
SECTION III — TYPE OF TREATMENT REQUESTED
7. Designate the type of treatment requested.
Primary Intensive Outpatient Treatment
•
Individual
Group
Family
•
Number of minutes per session
____ Individual
____ Group
____ Family
•
Twice / month
Once / month
Once / week
Other (Specify)
Sessions will be
•
Requesting ____ hours per week, for ____ weeks
•
Anticipating beginning treatment date
•
Estimated intensive treatment termination date
•
Attach a copy of treatment design, which includes the following:
a)
Schedule of treatment (day, time of day, length of session, and service to be provided during that time).
b)
Description of aftercare / follow-up component.
Aftercare / Follow-Up Service
•
Individual
Group
Family
•
Number of minutes per session
____ Individual
____ Group
____ Family
•
Once / week Other (Specify)
Sessions will be
Twice / month
Once / month
•
Requesting ____ hours per week, for ____ weeks
•
Estimated discharge date from this component of care
Continued
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