Prior Authorization / Durable Medical Equipment Attachment

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
DHS 107.24(3), Wis. Admin. Code
F-11030 (07/12)
DHS 152.06(3)(h), DHS 153.06(3)(g), DHS 154.06(3)(g), Wis. Admin. Code
FORWARDHEALTH
PRIOR AUTHORIZATION / DURABLE MEDICAL EQUIPMENT ATTACHMENT (PA/DMEA)
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/Durable Medical Equipment Attachment (PA/DMEA) Completion Instructions, F-
11030A.
SECTION I — MEMBER INFORMATION
1.
Name — Member (Last, First, Middle Initial)
2.
Age — Member
3.
Member Identification Number
SECTION II — PROVIDER INFORMATION
4.
Name — Prescribing Physician
5.
Prescribing Physician’s National Provider
Identifier
6.
Telephone Number — Prescribing Physician
7.
Telephone Number — Dispensing Provider
SECTION III — SERVICE INFORMATION
8.
Describe the overall physical status of the member (mobility, self-care, strength, coordination).
9.
Describe the medical condition of the member as it relates to the equipment / item requested (e.g., describe why the member
needs this equipment).
Continued

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