STATE OF WISCONSIN
DHS 106.03(4), Wis. Admin. Code
DEPARTMENT OF HEALTH SERVICES
Division of Medicaid Services
F-11018 (05/2013)
DHS 152.06(3)(h), 153.06(3)(g), 154.06(3)(g), Wis. Admin. Code
FORWARDHEALTH
PRIOR AUTHORIZATION REQUEST FORM (PA/RF)
Providers may submit prior authorization (PA) requests by fax to ForwardHealth 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 service-specific Prior Authorization
Request Form (PA/RF) Completion Instructions.
SECTION I — PROVIDER INFORMATION
1. Check only if applicable
HealthCheck “Other Services”
Wisconsin Chronic Disease Program (WCDP)
2. Process Type
3. Telephone Number ― Billing Provider
4. Name and Address — Billing Provider (Street, City, State, ZIP+4 Code) 5a. Billing Provider Number
5b. Billing Provider Taxonomy Code
6a. Name — Prescribing / Referring / Ordering Provider 6b. National Provider Identifier — Prescribing / Referring /
Ordering Provider
SECTION II — MEMBER INFORMATION
7. Member Identification Number 8. Date of Birth — Member 9. Address — Member (Street, City, State, ZIP Code)
10. Name — Member (Last, First, Middle Initial) 11. Gender — Member
Male Female
SECTION III — DIAGNOSIS / TREATMENT INFORMATION
12. Diagnosis — Primary Code and Description 13. Start Date — SOI 14. First Date of Treatment — SOI
15. Diagnosis — Secondary Code and Description 16. Requested PA Start Date
17. Rendering
Provider
Number
18. Rendering
Provider
Taxonomy
19. Service
Code
21.
POS
22. Description of Service 23. QR 24. Charge
1 2 3 4
An approved authorization does not guarantee payment. Reimbursement is contingent upon enrollment of the member and provider at the time the service is
provided and the completeness of the claim information. Payment will not be made for services initiated prior to approval or after the authorization expiration
date. Reimbursement will be in accordance with ForwardHealth payment methodology and policy. If the member is enrolled in a BadgerCare Plus Managed
Care Program at the time a prior authorized service is provided, ForwardHealth reimbursement will be allowed only if the service is not covered by the
Managed Care Program.
25. Total
Charges
26. SIGNATURE — Requesting Provider
27. Date Signed
