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Get ForwardHealth Prior Authorization / Residential Care Center Treatment Services Attachment

ARE CENTER TREATMENT SERVICES ATTACHMENT (PA/RCCA) For Initial Admission and Unplanned Readmission Within 90 Days of Discharge from RCC Instructions: Type or print clearly. Before completing this form, read the PA/RCCA Completion Instructions, F-11076C. SECTION I MEMBER INFORMATION 1. Name Member (Last, First, Middle Initial) 2. Date of Birth 3. Member Identification Number 5. National Provider Identifier SECTION II PROVIDER INFORMATION 4. Name Residential Care Center (R.

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