The IRS form F 11083 is for use by organizations that are responsible for disposing of federal tax records. This form allows the organization to certify that it has disposed of the tax records in accordance with Department of Treasury regulations. The disposal must be completed within 90 days after the organization's fiscal year end. The form must be signed by an authorized representative of the organization. Organizations that are responsible for disposing of federal tax records must complete Form F 11083 and submit it to the Internal Revenue Service (IRS). The form certifies that the records were disposed of in accordance with Department of Treasury regulations. The disposal must be completed within 90 days after the organization's fiscal year end. Signing this form is optional, but highly recommended, as it provides proof that the disposal was carried out properly. Organizations should take care to dispose of their federal tax records in a timely and safe manner, using a metho
| Question | Answer |
|---|---|
| Form Name | F 11083 Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | forward health drug prior authorization forms, forward health pa forms, forwardhealth prior authorization form, forward health prior authorization |
DEPARTMENT OF HEALTH SERVICES |
STATE OF WISCONSIN |
Division of Health Care Access and Accountability |
DHS 107.10(2), Wis. Admin. Code |
DHS 152.06(3)(h), DHS 153.06(3)(g), DHS 154.06(3)(g), Wis. Admin. Code |
FORWARDHEALTH
PRIOR AUTHORIZATION / BRAND MEDICALLY NECESSARY ATTACHMENT (PA/BMNA)
INSTRUCTIONS: Type or print clearly. Before completing this form, read the Prior Authorization/Brand Medically Necessary Attachment (PA/BMNA) Completion Instructions,
Prescribers are required to submit this completed form to the dispensing provider where the prescription will be filled.
Pharmacy providers may submit prior authorization (PA) requests with attachments to ForwardHealth by fax at (608)
SECTION I — MEMBER INFORMATION
1. Name — Member (Last, First, Middle Initial)
2. Date of Birth — Member
3. Member Identification Number
SECTION II — PRESCRIPTION INFORMATION
4. Drug Name
5. Strength(s)
6. National Drug Code (NDC)
7. Date Prescription Written
8. Directions for Use
9. Start Date Requested
10. Name — Prescriber
11. National Provider Identifier
12.Address — Prescriber (Street, City, State, ZIP+4 Code)
13.Telephone Number — Prescriber
14. Is “Brand Medically Necessary” handwritten by the prescriber on the prescription? |
Yes |
No |
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SECTION III — CLINICAL INFORMATION
15.Diagnosis — Primary Code and / or Description
16.Has the member experienced a clinically significant adverse reaction to the
generic equivalent drug? |
Yes |
No |
If yes, indicate the adverse reaction that can be directly attributed to the generic equivalent drug and the dose and approximate dates the drug was taken.
17. Has the member experienced a treatment failure with the generic equivalent drug? |
Yes |
No |
If yes, indicate the treatment failure that can be directly attributed to the generic equivalent drug and the dose and approximate dates the drug was taken.
Continued
PRIOR AUTHORIZATION / BRAND MEDICALLY NECESSARY ATTACHMENT (PA/BMNA) |
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SECTION III — CLINICAL INFORMATION (CONTINUED) |
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18. Has the member experienced an allergic reaction to the generic equivalent drug? |
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Yes |
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No |
Do you anticipate that the brand name drug will not cause the same allergic reaction? |
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Yes |
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No |
If yes, indicate the allergic reaction that can be directly attributed to the generic equivalent drug and the dose and approximate dates the drug was taken, if known.
19.Explain how the brand medically necessary drug will prevent the recurrence of the adverse reaction, treatment failure, or allergic reaction described in Elements 16, 17, and 18.
20.Does the member have a medical condition that causes a contraindication to the
use of the generic equivalent drug? |
Yes |
No |
If yes, indicate the medical condition and why or how the condition impacts the use of the generic equivalent drug.
SECTION IIIB — CLINICAL INFORMATION FOR NARROW THERAPEUTIC INDEX DRUGS
21.For the Following Drugs Only: Any Brand Name Anticonvulsant Drug Used to Treat a Seizure Disorder, Clozaril, Coumadin, Neoral, or Prograf
Does the member’s past medical history suggest an anticipated treatment |
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failure of the generic equivalent drug? |
Yes |
No |
If yes, indicate the prescriber’s documentation of the anticipated therapeutic failure* and the past medical history that forms the basis of the anticipated therapeutic failure.
*Therapeutic failure applies to treatment for seizure disorders.
22. SIGNATURE — Prescriber
23. Date Signed
SECTION IV — ADDITIONAL INFORMATION
24. Additional diagnostic and clinical information explaining the need for the drug required may be included below.