Get Wi F-00212a 2019-2026

The WI F-00212A is an essential form for requesting prior authorization for intensive in-home mental health and substance abuse services in Wisconsin. This guide provides a step-by-step approach to filling out the form correctly, ensuring that all necessary information is included for timely processing.

Follow the steps to successfully complete the WI F-00212A online.

1. Click ‘Get Form’ button to access the WI F-00212A form and open it in your preferred editor.
2. In Section I, enter the member's information. Start with Element 1 by inputting the last name, first name, and middle initial. Refer to Wisconsin's Enrollment Verification System (EVS) to confirm the correct spelling.
3. In Section II, complete Elements 4 through 8. Begin with Element 4 by entering the date of the initial assessment or reassessment.
4. Continue filling Section III for subsequent prior authorization requests if needed. In Element 12, note any changes in Elements 1–8, including the current Global Assessment of Functioning.
5. Finally, complete Section VI with the required signatures. Elements 21 to 25 need the signatures and dates from both the certified psychotherapist/substance abuse counselor and the member or their legal guardian.
6. Once all elements are filled, review the form for accuracy. Save your changes, and if needed, download or print the form for submission.

Complete your WI F-00212A form online today to ensure prompt processing of your prior authorization request.