DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN
Division of Medicaid Services
F-01176 (09/2022)
FORWARDHEALTH
PRIOR AUTHORIZATION FAX COVER SHEET
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It may contain information that is privileged, confidential, or exempt from disclosure under applicable law.
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Questions: For specific prior authorization (PA) questions, providers should call Provider Services at (800) 947-9627.
TO
Date Sent
Name
ForwardHealth PA
Fax Number
(608) 221-8616
FROM (Sender)
Name — Provider Contact Person
Number of Pages
Including This
Cover Sheet
Fax Number
Provider Number
Telephone Number
Name — Organization
COMMENTS / INSTRUCTIONS
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