PRIOR AUTHORIZATION / HOME HEALTH THERAPY ATTACHMENT (PA ...
DEPARTMENT OF HEALTH SERVICESSTATE OF WISCONSINDivision of Medicaid ServicesDHS 107.11(3), Wis. Admin. CodeF-11044 (07/2012)FORWARDHEALTHPRIOR AUTHORIZATION / HOME HEALTH THERAPY ATTACHMENT (PA/HHTA)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, 313 Blettner Boulevard, Madison, WI 53784. Instructions: Type or print clearly. Before completing this form, read the Prior Authorization/Home Health Therapy Attachment (PA/HHTA) Completion Instructions, F-11044A.SECTION I — MEMBER INFORMATIONName — Member (Last, First, Middle Initial) FORMTEXT ?????Age — Member FORMTEXT ?????Member Identification Number FORMTEXT ?????SECTION II — PROVIDER INFORMATIONName and Credentials — Therapist FORMTEXT ?????Therapist’s National Provider Identifier (NPI) FORMTEXT ?????Telephone Number — Therapist FORMTEXT ?????Name — Referring / Prescribing Physician FORMTEXT ?????Referring / Prescribing Physician’s NPI FORMTEXT ?????SECTION III — DOCUMENTATIONProvide a brief history pertinent to the service(s) requested. FORMTEXT ?????Provide a description of the member’s diagnosis and problems as they pertain to the need for the therapy services requested. (Include the date of onset.) FORMTEXT ?????Continued5257800902970000PRIOR AUTHORIZATION / HOME HEALTH THERAPY ATTACHMENT (PA/HHTA)Page 2 of 2F-11044 (07/2012)SECTION III — DOCUMENTATION (Continued)State member’s therapy history. (Indicate type / date / location for all types of therapy.)Service AreaLocationDateProblem TreatedPhysical Therapy FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Occupational Therapy FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Speech and Language Pathology FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Indicate the date of initial evaluation. (Supply dates / tests used / results of additional evaluations.) FORMTEXT ?????Describe progress in measurable / functional terms since treatment was initiated or last authorized. FORMTEXT ?????Attach a plan of care indicating specific, measurable goals and procedures to meet those goals. Describe rehabilitation potential. FORMTEXT ?????SIGNATURE — Requesting Provider FORMTEXT ?????Date Signed FORMTEXT ????? ................
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