Free ForwardHealth Private Duty Nursing Prior Authorization Acknowledgement, F11041 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11041 (10/08)

STATE OF WISCONSIN HFS 107.12(2), Wis. Admin. Code

FORWARDHEALTH

PRIVATE DUTY NURSING PRIOR AUTHORIZATION ACKNOWLEDGEMENT
ForwardHealth requires certain information to enable the programs to authorize and pay for medical services provided to eligible members. Members of ForwardHealth are required to give providers full, correct, and truthful information for the submission of correct and complete claims for reimbursement. This information should include, but is not limited to, information concerning enrollment status, accurate name, address, and member identification number (HFS 104.02[4], Wis. Admin. Code). Under s. 49.45(4), Wis. Stats., personally identifiable information about program applicants and members is confidential and is used for purposes directly related to ForwardHealth administration such as determining eligibility of the applicant, processing prior authorization (PA) requests, or processing provider claims for reimbursement. Failure to supply the information requested by the form may result in denial of PA or payment for the services. The use of this form is mandatory. INSTRUCTIONS 1. Allow the member, or member's parent, guardian, or legal representative, to read the plan of care and PA request. Answer any questions the member may have. 2. 3. 4. Have the member or the member's legal representative sign and date this form. Attach this completed form to the Prior Authorization Request Form (PA/RF), F-11018, and/or Prior Authorization Amendment Request, F-11042. Providers should make duplicate copies of all paper documents mailed to ForwardHealth. For more information on private duty nursing documentation, contact Provider Services at (800) 947-9627. Member Identification Number

Name -- Member

I have read the attached Plan of Care and the PA request. Name -- Person Signing Form (Print) Relationship to Member (If Person Signing Form Is Not Member)

SIGNATURE -- Person Signing Form

Date Signed

Check one of the following to identify person signing form. Member Member's Parent Guardian Legal Representative

Reset Form