Wisconsin Medicaid and BadgerCare Plus require this two-page cover form with most fee-for-service prior authorization requests, paired with a service-specific attachment such as the PA/DMEA or PA/OA. A clinician meets it when ordering a service, drug or item that needs approval first. It holds the provider, member, diagnosis and requested service lines, while the attachment holds the service-specific clinical detail.
The requesting provider completes the whole form: billing provider details, the prescribing, referring or ordering provider's name and NPI, member information, diagnosis codes, the requested PA start date and each service line. The requesting provider signs and dates it; there is no member or employer section.
Download the current version from the source each time; forms change without notice.
ForwardHealth Prior Authorization Request Form (PA/RF)
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Not usually. The PA/RF is used for Wisconsin Medicaid and BadgerCare Plus fee-for-service prior authorization, and HMO members go through their HMO's own process. Drugs are the exception: Wisconsin carves pharmacy out to fee-for-service for all members, so drug requests still go to ForwardHealth.
It depends on the service. ForwardHealth pairs the PA/RF with a service-specific attachment: for example the PA/DMEA for durable medical equipment, PA/OA for oxygen, PA/ENFA for enteral formula, PA/HHTA for home health therapy and PA/TA for outpatient therapy. The attachment carries the clinical detail for that service.
Yes. Providers can submit through the prior authorization function of the ForwardHealth Portal, or fax or mail the PA/RF and attachment to the ForwardHealth PA unit. The F-01176 PA Fax Cover Sheet is the fax companion, and changes to an existing request use the F-11042 PA Amendment Request.