Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11021 (10/08)

STATE OF WISCONSIN HFS 106.03(4), Wis. Admin. Code

FORWARDHEALTH

PRIOR AUTHORIZATION REQUEST / HEARING INSTRUMENT AND AUDIOLOGICAL SERVICES (PA/HIAS2)
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, 6406 Bridge Road, Madison, WI 53784-0088. Instructions: Type or print clearly. Before completing this form, read the Prior Authorization/Hearing Instrument and Audiological Services (PA/HIAS2) Completion Instructions, F-11021A. SECTION I -- PROVIDER INFORMATION 1. Name -- Provider 2. National Provider Identifier 3. Telephone Number -- Provider SECTION II -- MEMBER INFORMATION 5. Name -- Member (Last, First, Middle Initial) 7. Member Identification Number 6. Date of Birth -- Member 8. Gender -- Member Male 10. Describe Prior Hearing Instrument Use SECTION III -- DOCUMENTATION 13.
Legend Air Ear Right Left Unmasked Masked Bone Unmasked 0 Masked NR 10 Hearing Level in Decibels (dB) ANSI (1996) 20 30 40 50 60 70 80 90 100 Most comfortable level (dB-HL) 110 120

4. Address -- Provider (Street, City, State, ZIP+4 Code)

Female

11. Testing Date

9. Has the Member Ever Used a Hearing Instrument? Yes No 12. Test Reliability (Check One) Good Fair Poor

14. Pure Tone Audiogram -- Frequency in Hertz (Hz)
-10 125 250 500 1000 2000 4000 8000

___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
750 1500 3000 6000

o-o x-x

- -

< >

[ ]

SPEECH AUDIOMETRY Threshold (SRT or SDT) Word recognition in quiet Word recognition in noise Uncomfortable level (dB-HL)

R

L

SF

15. Additional Audiometric Studies and Results, Pertinent Social Background, Other Relevant Information (Use an Attachment if Necessary)

16. Recommendations for a Hearing Instrument (use an attachment if necessary) Ear (Check One) Left Right Both Ear Mold Style_________________ Hearing Aid Style________________ Ear Mold Left Right Both

Describe Electroacoustic Specifications

Special Modifications 17. SIGNATURE -- Requesting Provider 18. Name -- Requesting Provider (Print) 19. Provider Type (Check One)
Audiologist Hearing Instrument Specialist

20. Date Signed

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