Prior Authorization Vision Services Attachment

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
DHS 107.20(2), Wis. Admin. Code
F-11051 (07/12)
FORWARDHEALTH
PRIOR AUTHORIZATION / VISION SERVICES ATTACHMENT (PA/VA)
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/Vision Services Attachment (PA/VA) Completion Instructions, F-11051A.
SECTION I — MEMBER INFORMATION
1.
Name — Member (Last, First, Middle Initial)
2.
Age — Member
3.
Member Identification Number
SECTION II — PROVIDER INFORMATION
4.
Name — Referring / Prescribing Provider
5.
Referring / Prescribing Provider National Provider Identifier
6.
Telephone Number — Referring / Prescribing Provider
SECTION III — DOCUMENTATION
7.
Lenses and Frames (Lens formula information is required for all requests for frames and lenses.)
Lens formula
(L) ___________
Add ____________
(R) ___________
Replacement only
Frame name _________________________________________________
Frame manufacturer ___________________________________________
Replacement only

Complete appliance (lenses and frames)
8.
Special Lens / Frame Request



Oversize
Patient-supplied frame
Noncontract frame (not supplied by member)


Add over +4.00
Contract lab-supplied frame
Justification for noncontract frame (principal justification may not be cosmetic; principal justification must be medically / visually
necessary)
Other (provide pertinent history / findings and justification along with specifics of request)
If request is for a noncontract item, estimate wholesale cost
Continued

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