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Prior Authorization

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DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

Division of Health Care Access and Accountability

DHS 107.10(2)(c), Wis. Admin. Code

F-11054 (10/12)

DHS 152.06(3)(h), DHS 153.06(3)(g), DHS 154.06(3)(g), Wis. Admin. Code

FORWARDHEALTH

PRIOR AUTHORIZATION / ENTERAL NUTRITION PRODUCTS ATTACHMENT (PA/ENPA)

Instructions: Type or print clearly. Before completing this form, read the Prior Authorization/Enteral Nutrition Products Attachment

(PA/ENPA) Completion Instructions, F-11054A. Providers may refer to the Forms page of the ForwardHealth Portal at

for the completion instructions.

SECTION I — MEMBER INFORMATION

1. Name — Member (Last, First, Middle Initial)

2. Member Identification Number

3. Date of Birth — Member

4. Gender — Member

 Male

 Female

SECTION II — PRESCRIBER INFORMATION

5. Name — Prescriber

6. National Provider Identifier — Prescriber

7. Address — Prescriber (Street, City, State, ZIP+4 Code)

8. Telephone Number — Prescriber

SECTION III — PRESCRIPTION OR ORDER INFORMATION (Submit a copy of the prescription or order not greater than one

year old with each PA request.)

9. Indicate the product trade name(s) and calories per day of the enteral nutrition product(s) prescribed or ordered.

A. Product Trade Name ____________________________________ Calories / Day __________

B. Product Trade Name ____________________________________ Calories / Day __________

C. Product Trade Name ____________________________________ Calories / Day __________

10. Indicate the date the prescription or order was written. Prescriptions or orders should not be greater than one year old.

SECTION IV — DIETARY ASSESSMENT AND PLAN

11. Indicate the member’s total daily caloric requirements. Total daily caloric requirements are the calculated caloric needs from all

nutritional sources.

Continued

Prior Authorization

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