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DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11076B (10/08)

STATE OF WISCONSIN HFS 107.22, Wis. Admin. Code

FORWARDHEALTH

PRIOR AUTHORIZATION / RESIDENTIAL CARE CENTER TREATMENT SERVICES ATTACHMENT (PA/RCCA) For Continuing Services
Instructions: Type or print clearly. Before completing this form, read the PA/RCCA Completion Instructions, F-11076C. SECTION I -- MEMBER INFORMATION 1. Name -- Member (Last, First, Middle Initial) 2. Date of Birth 3. Member Identification Number

SECTION II -- PROVIDER INFORMATION 4. Name ­ Residential Care Center (RCC) 5. National Provider Identifier

SECTION III -- CLINICAL INFORMATION 6. 7. 8. Attach documentation of a HealthCheck screen by a valid HealthCheck screener dated within one year prior to the first date of service requested. Attach a copy of the in-depth assessment performed within 30 days of admission which has been timely reviewed and signed by a physician or other licensed mental health professional. Attach a copy of the detailed narrative describing progress on the goals of earlier treatment plans, as well as a copy of the current treatment plan, dated within three months of the requested first date of service, which has been timely reviewed and signed by a physician or other licensed mental health professional. Indicate the expected schedule if the member is receiving intermittent services for stabilization at the RCC.

SECTION IV -- SIGNATURE 9. SIGNATURE -- Residential Care Center Clinical Supervisor 10. Date Signed

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