Revocation Of Power Of Attorney For Health Care Wi Page 3
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4PRIOR AUTHORIZATION / SUBSTANCE ABUSE ATTACHMENT (PA/SAA)
Page 3 of 4
F-11032 (07/12)
SECTION IV — DOCUMENTATION (Continued)
11. Provide current primary and secondary diagnosis (refer to the current Diagnostic and Statistical Manual of Mental Disorders)
codes and descriptions.
12. Describe the member’s current clinical problems and relevant history. Include substance abuse history.
13. Describe the member’s family situation. Include how family issues are being addressed and if family members are involved in
treatment. If family members are not involved in treatment, specify why not.
14. Provide a detailed description of treatment objectives and goals.
Continued
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