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Date: January 27, 2009
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State: Wisconsin
Category: Health Care
Author: DHCAA-BPI
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http://dhs.wisconsin.gov/forms/F1/F11076A.pdf

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

STATE OF WISCONSIN HFS 107.22, Wis. Admin. Code

FORWARDHEALTH

PRIOR AUTHORIZATION / RESIDENTIAL CARE CENTER TREATMENT SERVICES ATTACHMENT (PA/RCCA) For Initial Admission and Unplanned Readmission Within 90 Days of Discharge from RCC
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. By my signature, I hereby attest that the following are true: The member named above has been admitted to the RCC named above on the date given in Element 14 of the PA/RF. The member has received a HealthCheck screen performed and signed by a valid HealthCheck screener and dated not more than one year prior to the date of admission to the RCC. Within 30 days of admission, the RCC staff shall perform an in-depth assessment of the member, which will be reviewed timely and signed by a physician or other licensed mental health professional, according to HFS 52.22 (1). Within 30 days of admission, and at least every three months thereafter, the RCC staff shall develop and implement a treatment plan, which will be reviewed timely and signed by a physician or other licensed mental health professional, according to HFS 52.22 (2) and (3). The RCC shall record in the resident's treatment record all services provided, according to HFS 52.49 and HFS 106.02 (9).

SECTION IV -- ATTACHMENTS AND SIGNATURE 7. The following materials must be attached and labeled: In accordance with HFS 52.21 (2) and HFS 101.03 (96m): a. An Admission Screening Report that documents the admission is medically necessary and appropriate. b. An initial admission treatment plan developed with the member that addresses the member's presenting problem. I attest to the accuracy of the information on this PA request. SIGNATURE Residential Care Center Clinical Supervisor

8.

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Date Signed

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