Prior Authorization / Care Plan Attachment (PA/CPA), F-11096



5198110923099500DEPARTMENT OF HEALTH SERVICESSTATE OF WISCONSINDivision of Health Care Access and AccountabilityWis. Admin. Code § DHS 107.11(3)F-11096 (08/15)FORWARDHEALTHPRIOR AUTHORIZATION / CARE PLAN ATTACHMENT (PA/CPA)Instructions: Print or type clearly. Refer to the Required Information for Prior Authorization/Care Plan Attachment (PA/CPA), Completion Instructions, F-11096A, for information about completing this form.SECTION I — MEMBER INFORMATION1. Name — Member FORMTEXT ?????2. Telephone Number — Member FORMTEXT ?????3. Member Identification Number FORMTEXT ?????4. Start of Care Date FORMTEXT ?????5. Certification PeriodFrom FORMTEXT ?????To FORMTEXT ?????SECTION II — PERTINENT DIAGNOSES AND PROBLEMS TO BE TREATED6. Principal Diagnosis (International Classification of Diseases [ICD] Code, Description, Date of Diagnosis) FORMTEXT ?????7. Surgical Procedure and Other Pertinent Diagnoses (ICD Code, Description, Date of Procedure or Diagnoses) FORMTEXT ?????SECTION III — BRIEF MEDICAL AND SOCIAL INFORMATION8. Durable Medical Equipment FORMTEXT ?????9. Functional Limitations1 FORMCHECKBOX Amputation2 FORMCHECKBOX Bowel / Bladder (Incontinence)3 FORMCHECKBOX Contracture 4 FORMCHECKBOX Hearing 5 FORMCHECKBOX Paralysis 6 FORMCHECKBOX Endurance 7 FORMCHECKBOX Ambulation 8 FORMCHECKBOX Speech 9 FORMCHECKBOX Legally Blind10 FORMCHECKBOX Dyspnea with Minimal Exertion11 FORMCHECKBOX Other (Specify other functional limitations in the space provided.) FORMTEXT ?????10. Activities Permitted1 FORMCHECKBOX Complete Bedrest2 FORMCHECKBOX Bedrest BRP 3 FORMCHECKBOX Up As Tolerated 4 FORMCHECKBOX Transfer Bed / Chair5 FORMCHECKBOX Exercises Prescribed 6 FORMCHECKBOX Partial Weight Bearing7 FORMCHECKBOX Independent at Home 8 FORMCHECKBOX Crutches9 FORMCHECKBOX Cane10 FORMCHECKBOX Wheelchair11 FORMCHECKBOX Walker12 FORMCHECKBOX No Restrictions13 FORMCHECKBOX Other (Specify other activities permitted in the space provided.) FORMTEXT ?????ContinuedPRIOR AUTHORIZATION / CARE PLAN ATTACHMENT (PA/CPA)2 of 4F-11096 (08/15)SECTION III — BRIEF MEDICAL AND SOCIAL INFORMATION (Continued)11. Medications (Dose / Frequency / Route) FORMTEXT ?????12. Allergies FORMTEXT ?????13. Nutritional Requirements FORMTEXT ?????14. Mental Status1 FORMCHECKBOX Oriented3 FORMCHECKBOX Forgetful5 FORMCHECKBOX Disoriented7 FORMCHECKBOX Agitated2 FORMCHECKBOX Comatose4 FORMCHECKBOX Depressed6 FORMCHECKBOX Lethargic8 FORMCHECKBOX Other FORMTEXT ?????15. Prognosis1 FORMCHECKBOX Poor2 FORMCHECKBOX Guarded3 FORMCHECKBOX Fair4 FORMCHECKBOX Good5 FORMCHECKBOX Excellent SECTION IV — ORDERS16. Orders for Services and Treatments (Number / Frequency / Duration) FORMTEXT ?????ContinuedPRIOR AUTHORIZATION / CARE PLAN ATTACHMENT (PA/CPA)3 of 4F-11096 (08/15)SECTION IV — ORDERS (Continued)17. Goals / Rehabilitation Potential / Discharge Plans FORMTEXT ?????SECTION V — SUPPLEMENTARY MEDICAL INFORMATION18. Date Physician Last Saw Member FORMTEXT ?????19. Dates of Last Inpatient Stay Within 12 Months (If Known)Admission FORMTEXT ?????Discharge FORMTEXT ?????20. Type of Facility for Last Inpatient Stay (If Applicable) FORMTEXT ?????21. Current Information (Summary from Each Discipline / Treatments / Clinical Facts) FORMTEXT ?????22. Home or Social Environment FORMTEXT ?????23. Medical and / or Nonmedical Reasons Member Regularly Leaves Home (Include Frequency) FORMTEXT ?????ContinuedPRIOR AUTHORIZATION/CARE PLAN ATTACHMENT (PA/CPA)4 of 4F-11096 (08/15)SECTION V — SUPPLEMENTARY MEDICAL INFORMATION (Continued)24. Names of Other Providers with Whom This Case Is Shared FORMTEXT ?????SECTION VI — SIGNATURESNurse CertificationAs the nurse completing this plan of care (POC), I confirm the following: All information entered on this form is complete and accurate, and I am familiar with all of the information entered on this form. 25. SIGNATURE — Authorized Registered Nurse (RN) Completing Form26. Date Signed by Authorized RN Completing Form FORMTEXT ?????27. Date of Verbal Orders for Initial Certification Period FORMTEXT ?????28. Date Physician-Signed Form Received FORMTEXT ?????Physician CertificationThe member is under my care, and I have ordered the services on this POC.29. Name and Address — Attending Physician (Street, City, State, ZIP+4 Code) FORMTEXT ?????30. SIGNATURE — Attending Physician31. Date Signed — Attending Physician FORMTEXT ?????Case Sharing ProviderAs a provider countersigning this POC, I confirm the following: All information entered on this form is complete and accurate, and I am familiar with all of the information entered on this form. 32. COUNTERSIGNATURE33. Date Countersigned FORMTEXT ?????Anyone who misrepresents, falsifies, or conceals essential information required for payment of state and/or federal funds may be subject to fine, imprisonment, or civil penalty under applicable state and/or federal laws. ................
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