Wisconsin Medicaid uses this two-page attachment with the PA/RF when home oxygen or respiratory equipment needs prior authorization. It records whether the request is initial or subsequent, continuous or PRN oxygen, the oxygen type, and whether it is stationary or portable. A second section covers the equipment: primary or secondary unit, and new, rental renewal or replacement.
The prescribing practitioner and the oxygen supplier complete it together. Section IV records the requesting provider's name and the name, email address, signature and date of the person who filled out the form.
Download the current version from the source each time; forms change without notice.
Prior Authorization/Oxygen Attachment (PA/OA)
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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Element 8 asks whether the request is for a primary unit, a secondary unit or both, so a single PA/OA can cover both. Element 7 separately records whether the oxygen is stationary or portable, and Element 6 the type: concentrator, liquid or gaseous.
No. The form states it is only for oxygen and respiratory durable medical equipment, and providers must request disposable medical supplies on a separate PA request. ForwardHealth's disposable medical supplies attachment is F-03432.
Yes. Element 9 asks whether the request is for new DME, renewing a rental or replacing existing DME, and Element 4 marks the clinical request as initial or subsequent. A subsequent request notes whether the amount matches what ForwardHealth granted last time.