Prior Authorization
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1
2DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
DHS 107.06(2), Wis. Admin. Code
F-11034 (07/12)
DHS 152.06(3)(h), 153.06(3)(g), 154.06(3)(g), Wis. Admin. Code
FORWARDHEALTH
PRIOR AUTHORIZATION / “J” CODE ATTACHMENT (PA/JCA)
Providers may submit prior authorization (PA) requests with attachments to ForwardHealth by fax at (608) 221-8616 or by mail
to ForwardHealth, Prior Authorization, Suite 88, 313 Blettner Boulevard, Madison, WI 53784. Instructions: Type or print
clearly. Before completing this form, read the Prior Authorization/"J" Code Attachment (PA/JCA) Completion Instructions,
F-11034A.
SECTION I — MEMBER INFORMATION
1. Name — Member (Last, First, Middle Initial)
2. Date of Birth — Member
3. Member Identification Number
SECTION II — DRUG ORDER INFORMATION
4. Drug Name
5. Strength
6. National Drug Code
7. HCPCS “J” Code
8. Quantity Ordered
9. Date Order Issued
10. Daily Dose
11. Name — Prescriber
12. National Provider Identifier
13. “Brand Medically Necessary”
Yes
No
If yes, please indicate and describe the adverse reaction, allergic
reaction, or actual therapeutic failure in the space provided.
SECTION III — CLINICAL INFORMATION
14. Diagnosis
15. Changes to Previous Clinical Condition
Continued
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