Prior Authorization Substance Abuse Daily Treatment Attachment
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4DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
DHS 107.13(3m), Wis. Admin. Code
F-11037 (07/12)
FORWARDHEALTH
PRIOR AUTHORIZATION / SUBSTANCE ABUSE DAY TREATMENT ATTACHMENT (PA/SADTA)
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/Substance Abuse Day Treatment Attachment (PA/SADTA) Completion Instructions, F-11037A.
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 — Requesting / Rendering Provider
5. Telephone Number — Requesting / Rendering Provider
SECTION III — DOCUMENTATION
6. Describe length and intensity of treatment requested.
•
Program request is for
hours per day,
days per week,
for
weeks,
for a total of
hours.
•
Anticipated beginning treatment date
.
•
Estimated substance abuse day treatment discharge date
.
•
Attach a copy of treatment design, which includes the following:
a.
A schedule of treatment (day, time of day, length of session, and service to be provided during that time).
b.
A brief description of aftercare / continuing care / follow-up component (also include this information in the treatment plan
section of this form).
7. List the dates of diagnostic evaluations or medical examinations and specific diagnostic procedures that were employed.
Continued
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