Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11031 (10/08)

STATE OF WISCONSIN HFS 107.13(2), Wis. Admin. Code

FORWARDHEALTH

PRIOR AUTHORIZATION / PSYCHOTHERAPY ATTACHMENT (PA / PSYA)
Providers may submit prior authorization (PA) requests 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/Psychotherapy Attachment (PA/PSYA) Completion Instructions, F-11031A. Failure to complete all elements could result in return or denial of PA request. Attach a copy of the member's assessment and treatment/recovery plan. Providers may submit this information on a new optional form, the Outpatient Mental Health Assessment and Treatment/Recovery Plan, F-11103. SECTION I -- MEMBER INFORMATION 1. Name -- Member (Last, First, Middle Initial) 2. Date of Birth -- Member 3. Member Identification Number

SECTION II -- PROVIDER INFORMATION 4. Name and Address -- Rendering Provider 6. Telephone Number -- Rendering Provider 5. Rendering Provider's National Provider Identifier 7. Discipline -- Rendering Provider

SECTION III -- SERVICE REQUEST Based on the information in the member's assessment and treatment/recovery plan or recorded on the optional Department of Health Services Outpatient Mental Health Assessment and Treatment/Recovery Plan, the following services are requested. 8. Number of Minutes Per Session Individual 9. Group Family Other _____

Frequency of Requested Sessions (Services in excess of once weekly require specific justification.) Monthly Twice / month Once / week Other _____

10. Total Number of Sessions / Hours Requested for This PA Period

11. Treatment Approach

12. Estimated Termination Date

13. SIGNATURE -- Rendering Provider

14. Date Signed

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