Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11018 (10/08)

STATE OF WISCONSIN HFS 106.03(4), Wis. Admin. Code HFS 152.06(3)(h), 153.06(3)(g), 154.06(3)(g), Wis. Admin. Code

FORWARDHEALTH

PRIOR AUTHORIZATION REQUEST FORM (PA/RF)
Providers may submit prior authorization (PA) requests by fax to ForwardHealth at (608) 221-8616 or by mail to: ForwardHealth, Prior Authorization, Suite 88, 6406 Bridge Road, Madison, WI 53784-0088. Instructions: Type or print clearly. Before completing this form, read the service-specific Prior Authorization Request Form (PA/RF) Completion Instructions.

SECTION I -- PROVIDER INFORMATION
1. Check only if applicable HealthCheck "Other Services" Wisconsin Chronic Disease Program (WCDP) 4. Name and Address -- Billing Provider (Street, City, State, ZIP+4 Code) 5a. Billing Provider Number 2. Process Type 3. Telephone Number Billing Provider

5b. Billing Provider Taxonomy Code

SECTION II -- MEMBER INFORMATION
6. Member Identification Number 7. Date of Birth -- Member 8. Address -- Member (Street, City, State, ZIP Code)

9. Name -- Member (Last, First, Middle Initial)

10. Gender -- Member Male Female

SECTION III -- DIAGNOSIS / TREATMENT INFORMATION
11. Diagnosis -- Primary Code and Description 12. Start Date -- SOI 13. First Date of Treatment -- SOI

14. Diagnosis -- Secondary Code and Description

15. Requested PA Start Date

16. Rendering Provider Number

17. Rendering Provider Taxonomy Code

18. Service Code

19. Modifiers 1 2 3 4

20. POS

21. Description of Service

22. QR

23. Charge

An approved authorization does not guarantee payment. Reimbursement is contingent upon enrollment of the member and provider at the time the service is provided and the completeness of the claim information. Payment will not be made for services initiated prior to approval or after the authorization expiration date. Reimbursement will be in accordance with ForwardHealth payment methodology and policy. If the member is enrolled in a BadgerCare Plus Managed Care Program at the time a prior authorized service is provided, ForwardHealth reimbursement will be allowed only if the service is not covered by the Managed Care Program.

24. Total Charges

$0.00

25. SIGNATURE -- Requesting Provider

26. Date Signed

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