ForwardHealth Prior Authorization Request Form (PA/RF)

Personal Care Work Services (PCW)
Prior Authorization Fax Form
Please complete all fields on the form and fax to: 866-273-2240
SECTION I — PROVIDER INFORMATION
1. Check request type
2. Process Type
 Routine
3. Telephone/Fax Number ― Billing Provider
 Urgent (urgent is defined as
“significant impact to health of the
member”)
Phone:
Initial request
Re-certification request
4. Name and Address — Billing Provider (Street, City, State, ZIP+4 Code)
Fax:
5a. Billing Provider Tax ID Number (TIN)
5b. Billing Provider Taxonomy Code (if available)
6a. Name — Prescribing / Referring / Ordering Provider
6b. National Provider Identifier — Prescribing / Referring /
Ordering Provider
SECTION II — MEMBER INFORMATION
8. Date of Birth — Member
7. Member Identification Number
10. Name — Member (Last, First, Middle Initial)
9. Address — Member (Street, City, State, ZIP Code)
11. Gender — Member
Male
Female
SECTION III — DIAGNOSIS / TREATMENT INFORMATION
12. Diagnosis — Primary Code and Description
13. Start Date — SOI
15. Diagnosis — Secondary Code and Description
16. Requested PA Start Date
17. Rendering
Provider
Number
18. Rendering
Provider
Taxonomy
Code
19. Service
Code
20. Modifiers
1
2
T1019
T1019
3
21.
POS
14. First Date of Treatment — SOI
22. Description of Service
23. QR
24. Charge
4
12
U3
99509
12
12
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. In order to process your request completely and timely, submit any pertinent clinical data ( i.e. progress notes, treatment rendered, tests, to support
request for services. Any request for OON services must include documentation on the reason for the request along with the name of the OON provider.
FAILURE TO PROVIDE SUFFICIENT INFORMATION W ILL RESULT IN A DELAY IN YOUR REQUEST .
25. Total
Charges
26. SIGNATURE — Requesting Provider
27. Date Signed
Coverage provided by UnitedHealthcare of Wisconsin, Inc.