Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11030 (10/08)

STATE OF WISCONSIN HFS 107.24(3), Wis. Admin. Code HFS 152.06(3)(h), HFS 153.06(3)(g), HFS 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, 6406 Bridge Road, Madison, WI 53784-0088. Instructions: Type or print clearly. Before completing this form, read the Prior Authorization/Durable Medical Equipment Attachment (PA/DMEA) Completion Instructions, F11030A. 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 Telephone Number -- Dispensing Provider

6.

Telephone Number -- Prescribing Physician

7.

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

PRIOR AUTHORIZATION / DURABLE MEDICAL EQUIPMENT ATTACHMENT (PA/DMEA) F-11030 (10/08)

Page 2 of 2

SECTION III -- SERVICE INFORMATION (continued) 10. Is the member able to operate the equipment / item requested? Yes No -- If not, who will do this?

11. Is training provided or required? Yes Explain. No -- If not, who will do this?

12. State where equipment / item will be used. Home Nursing Home School Describe type of dwelling and accessibility. Office Job

13. State estimated duration of need.

14. If renewal or continuation of DME authorization is requested, describe the following about the member, including current clinical condition, progress (improvement, no change, etc.), results, and the member's use of equipment / item prescribed.

15. Indicate amount of oxygen to be administered. ____ Liters per minute ____ Hours per day ____ Days per week Continuous PRN PaO2

Attach a photocopy of the physician's prescription to this attachment. The prescription must be signed and dated within six months of receipt by ForwardHealth. 16. SIGNATURE -- Requesting Provider 17. Date Signed

Reset Form