DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11038 (10/08)
STATE OF WISCONSIN HFS 107.13(4), Wis. Admin. Code
FORWARDHEALTH
PRIOR AUTHORIZATION / ADULT MENTAL HEALTH DAY TREATMENT ATTACHMENT (PA/AMHDTA)
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 Prior Authorization/Adult Mental Health Day Treatment Attachment (PA/AMHDTA) Completion Instructions, F-11038A. SECTION I -- MEMBER INFORMATION 1. Name -- Member (Last, First, Middle Initial) 2. Age -- Member
3.
Member Identification Number
SECTION II -- PROVIDER INFORMATION 4. Name and Credentials -- Requesting / Rendering Provider
5.
Requesting / Rendering Provider's National Provider Identifier (NPI)
6.
Telephone Number -- Requesting / Rendering Provider
7.
Name -- Referring / Prescribing Provider
8.
Referring / Prescribing Provider's NPI
SECTION III -- DOCUMENTATION 9. Number of Hours per Week Requested 10. Estimated Final Treatment Date
11. Has the member had previous adult mental health day treatment at the provider's facility or elsewhere? Yes No If "yes," list dates and locations. Unknown
12. Evaluation(s) (Include date[s], tests used, and results.)
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SECTION III -- DOCUMENTATION (Continued) 13. Attach Section I of the member's most recent Functional Assessment. (The Mental Health Day Treatment Functional Assessment, F-11090, must be signed and dated within three months of receipt by ForwardHealth.) 14. Is the member's intellectual functioning below average? Yes No If "yes," what is the member's IQ score or intellectual functioning level, and how was this measured?
15. Provide a brief history pertinent to requested services. (Include psycho-social history, hospitalization history, family history, living situation history, etc.)
16. Describe progress / status since treatment began or was last authorized, if applicable.
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SECTION III -- DOCUMENTATION (Continued) 17. Specify overall character of service to be provided. Rehabilitation Maintenance Stabilization
18. Identify measurable treatment goals.
19. Attach a specific schedule of activities, including date, time of day, length of session, and service to be provided.
20. Estimate the member's rehabilitation potential for employment (competitive, supported, sheltered, etc.), social interaction, and independent living.
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SECTION III -- DOCUMENTATION (Continued) I have read the attached requests for PA of adult mental health day treatment services and agree that it will be sent to ForwardHealth for review. 21. SIGNATURE -- Member or Representative 22. Date Signed
23. Relationship (If Representative)
24. SIGNATURE -- Prescribing Physician
25. Date Signed
26. SIGNATURE -- Therapist Providing Treatment
27. Date Signed
28. SIGNATURE -- 51.42 Board Director / Designee
29. Date Signed
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