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Wisconsin Medicaid PA/DMEA F-11030: DME Attachment

ForwardHealth uses this attachment with the PA/RF when durable medical equipment needs prior authorization under Wisconsin Medicaid. A clinician meets it when ordering equipment such as complex rehab technology, compression garments or pumps, or home health equipment. The 08/2026 revision is two pages, with one section for new equipment and another for repairing or replacing existing equipment.

Who completes it

The prescribing practitioner and the DME provider complete it together. Section V records the requesting provider's name and the name, email address, signature and date of the person who filled out the form.

Submitting and payment

How to submit it
Attach it to the PA/RF and submit it to ForwardHealth through the Portal, by fax or by mail; the form points to the ForwardHealth Online Handbook for PA submission instructions.

Good to know

  • Element 6 routes the request: new DME, rented or purchased, completes Section III, while repair or replacement of existing DME completes Section IV.
  • For a miscellaneous or 'priced on PA' HCPCS code such as E1399, give the make, model and description and attach the manufacturer's suggested retail price or a vendor invoice.
  • New-equipment requests must describe the cost-effective options the member already tried and why they did not meet the member's needs, and state whether the member has already rented the item.
  • Related attachments cover specific equipment: F-02891 DME Home Accessibility Report, F-03327 Pediatric Hospital Bed, F-11066 Oxygen, F-03432 Disposable Medical Supplies and F-03431 Orthotics and Prosthetics.

Get the official form

Download the current version from the source each time; forms change without notice.

Prior Authorization/Durable Medical Equipment Attachment (PA/DMEA)

Official pagePDF

How this list is checked

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.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

What does the PA/DMEA ask about the member's need?

Element 4 identifies the type of support: complex rehab technology, compression equipment such as garments or pumps, home health equipment, or other. Element 5 asks about how long the member will need it, either a number of months or the lifetime of the DME.

What does the PA/DMEA ask for a repair or replacement?

Section IV asks for the make and model of the device, when it was dispensed, whether it is under warranty, the reason (damaged, missing, worn out or other), whether the part has met its life expectancy, and whether the member's functional status or medical condition has changed since they first got it.

Is the PA/DMEA used for oxygen equipment?

Oxygen and respiratory equipment have their own attachment, the Prior Authorization/Oxygen Attachment (F-11066), and disposable medical supplies use F-03432. The PA/DMEA covers other durable medical equipment, including new rentals or purchases and repair or replacement of existing devices.