DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11029 (10/08)
STATE OF WISCONSIN HFS 107.15(3), Wis. Admin. Code
FORWARDHEALTH
PRIOR AUTHORIZATION / CHIROPRACTIC ATTACHMENT (PA/CA)
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/Chiropractic Attachment (PA/CA) Completion Instructions, F-11029A. SECTION I -- PROVIDER INFORMATION 1. Name -- Provider
2. Address -- Clinic or Office Where Service(s) Is Provided
3. National Provider Identifier
4. Telephone Number -- Provider
SECTION II -- MEMBER INFORMATION 5. Name -- Member (Last, First, Middle Initial) 6. Date of Birth -- Member
7. Member Identification Number
SECTION III -- SERVICE INFORMATION 8. Total Number of Services Requested (Specify) 9. Total Number of Weeks Requested
10. Requested Start Date of Prior Authorization
SECTION IV -- SUPPORTING INFORMATION 11. Date of Spell of Illness 12. Date of Beginning Treatment
13. History a) Initial
b) Spell of Illness
c) Previous and / or Concurrent Care
Continued
PRIOR AUTHORIZATION / CHIROPRACTIC ATTACHMENT (PA/CA) F-11029 (10/08)
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SECTION IV -- SUPPORTING INFORMATION (Continued) 14. Subjective Complaints a) Initial
b) Spell of Illness
15. Objective Findings a) Initial
b) Spell of Illness
c) Diagnosis
16. Subjective Progress
17. Objective Progress
18. Prognosis / Treatment Plan
19. Additional Comments
20. SIGNATURE -- Examining / Treating Provider
21. Date Signed
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