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File Size: 88.2 kB
Pages: 2
Date: January 27, 2009
File Format: PDF
State: Wisconsin
Category: Health Care
Author: DHCAA-BPI
Word Count: 243 Words, 1,726 Characters
Page Size: Letter (8 1/2" x 11")
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http://dhs.wisconsin.gov/forms/F1/F11029.pdf

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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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