Instructions for Form F-11054 Prior Authorization / Enteral Nutrition Formula Attachment (Pa / Enfa) - Wisconsin

Form F-11054 Prior Authorization/Enteral Nutrition Formula Attachment (Pa/Enfa) - Wisconsin

This document contains official instructions for Form F-11054 , Prior Authorization/Enteral Nutrition Formula Attachment (Pa/Enfa) - a form released and collected by the Wisconsin Department of Health Services. An up-to-date fillable Form F-11054 is available for download through this link.

FAQ

Q: What is Form F-11054?
A: Form F-11054 is the Prior Authorization/Enteral Nutrition Formula Attachment (Pa/Enfa) used in Wisconsin.

Q: What is the purpose of Form F-11054?
A: The purpose of Form F-11054 is to request prior authorization for enteral nutrition formula in Wisconsin.

Q: Who needs to fill out Form F-11054?
A: Healthcare providers or suppliers who are requesting prior authorization for enteral nutrition formula in Wisconsin need to fill out Form F-11054.

Q: What information is required on Form F-11054?
A: Form F-11054 requires information such as patient name, address, diagnosis, prescribed formula, duration of use, and healthcare provider's signature.

Q: Is Form F-11054 specific to Wisconsin?
A: Yes, Form F-11054 is specific to Wisconsin and is used for requesting prior authorization for enteral nutrition formula in the state.

Q: What is enteral nutrition formula?
A: Enteral nutrition formula is a liquid nutrition supplement that is delivered through a tube into the digestive tract. It is used when a person cannot eat or swallow normally.