FORWARDHOSPITAL.COM for more information on the use of this form. Fax numbers for your region are: Region: (1) Area Code :(2) State: (3) Post Office Box: (4) Fax Number: Fax(3) Email Address: Fax(4) Telephone Number: Fax(5) Please include the following information in any communication you may be sending or receiving with your request for a prior authorization: Your full name, address and state where your primary or secondary medical care provider has your primary care address The name and telephone number of your primary care physician, if applicable The name and number of your medical care provider(s) at each of the following locations and any emergency provider you may have If applicable, the name and telephone number of the laboratory or medical diagnostic facility where the prescription was obtained (if not obtained directly from the person seeking the prescription) The quantity dispensed and date The nature of your condition/illness/health status The quantity of the prescription dispensed and the names and addresses of the physician or other licensed health care professional(s) or laboratory/ medical diagnostic facility at which the prescription was dispensed, if applicable The name and address of the physician for your prescription In the case of multiple prescriptions for the same item(s), please specify the exact quantity dispensed and the last date you received the dosage. The address of your place(s) of business The name, business type, and telephone number of your principal legal officer (if different) In the case of multiple prescription(s) requesting a quantity greater than one or 2 prescriptions for the same item(s), please specify the quantity of each dispensed The names and addresses of the physicians you have and recommend for you or your children In accordance with the Pharmacy Practice Act of 1987, Section 8-102 (3) (c), for drug dispensed in this state, your pharmacy or health maintenance organization need not record which of your prescriptions is filled using this form. The information you supply above will be used to determine if your request has been approved. If we approve your request, we will transmit the required prior authorization information on official DEA Form 5220.6, Prescription. DEA approval information may take up to 7 working days to become available. If you do not receive an approval form within 10 working days, please check with us by phone during business hours.
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DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-00238 (06/12) STATE OF WISCONSIN DHS 107.10(2), Wis. Admin. Code FORWARDHEALTH PRIOR AUTHORIZATION / PREFERRED DRUG
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