Get Prior Authorization Request Form (pa/rf) - Forwardhealth Wi

Navigating the Prior Authorization Request Form (PA/RF) for Forwardhealth in Wisconsin can be straightforward with the right guidance. This comprehensive guide aims to help users effectively complete the form by providing detailed, step-by-step instructions tailored to your needs.

Follow the steps to submit your request with confidence.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by filling out SECTION I — PROVIDER INFORMATION. Include your process type and telephone number of the billing provider. Ensure you list the name and complete address of the billing provider accurately, along with the billing provider number and taxonomy code.
3. Proceed to SECTION II — MEMBER INFORMATION. Enter the member identification number, date of birth, full name, and address of the member. Double-check that all information corresponds with official documents for accuracy.
4. Move to SECTION III — DIAGNOSIS / TREATMENT INFORMATION. Document the primary diagnosis code and description, start date of service, first treatment date, and any secondary diagnosis information if applicable. Additionally, include the rendering provider number, taxonomy code, service code, and description of the service being requested.
5. Complete the financial sections, including total charges and any modifiers. Fill out the charge amounts for the services rendered as well as the total charges for the prior authorization request.
6. Finally, sign and date the form in the designated areas to validate the request. Ensure you keep a copy of this form for your records before submission.
7. Once you have reviewed the completed form for accuracy, you can save your changes, and if necessary, download, print, or share the form as needed for submission.

Complete your Prior Authorization Request Form online today for a smoother processing experience.