Free ForwardHealth Prior Authorization FAX Cover Sheet, F01176 - Wisconsin

DEPARTMENT OF HEALTH SERVICES F-1176 (10/08)

STATE OF WISCONSIN

FORWARDHEALTH

PRIOR AUTHORIZATION FAX COVER SHEET
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Date Sent TO Name

Telephone Numbers

Fax Number

ForwardHealth Prior Authorization (PA)
FROM (Sender) Name -- Provider Contact Person

PA questions -- (800) 947-9627 or (608) 221-9883 Fax questions -- (608) 221-4746, extension 80118

(608) 221-8616

Number of Pages Including This Cover Sheet

Fax Number

Provider Number

Telephone Number

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