Prior Authorization Amendment Request

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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-11042 (07/12)
DHS 152.06(3(h), 153.06(3)(g), 154.06(3)(g), Wis. Admin. Code
FORWARDHEALTH
PRIOR AUTHORIZATION AMENDMENT REQUEST
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. Refer to
the Prior Authorization Amendment Request Completion Instructions, F-11042A, for detailed information on completing this form.
SECTION I — MEMBER INFORMATION
1. Original PA Number
2. Process Type
3. Member Identification Number
4. Name — Member (Last, First, Middle Initial)
SECTION II — PROVIDER INFORMATION
5. Billing Provider Number
7. Address — Billing Provider (Street, City, State, ZIP+4 Code)
6. Name — Billing Provider
SECTION III — AMENDMENT INFORMATION
8. Requested Start Date
9. Requested End Date (If Different from Expiration Date of
Current PA)
10. Reasons for Amendment Request (Check All That Apply)
 Change Billing Provider Number
 Add Procedure Code / Modifier
 Change Procedure Code / Modifier
 Change Diagnosis Code
 Change Grant or Expiration Date
 Discontinue PA
 Change Quantity
 Other (Specify)_____________________________________________
11. Description and Justification for Requested Change
 Yes
 No
12. Are Attachments Included?
If Yes, specify attachments below.
13. SIGNATURE — Requesting Provider
14. Date Signed — Requesting Provider
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