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Get WI DHS F-11075 2011

RUG LIST (PA/PDL) EXEMPTION REQUEST Instructions: Type or print clearly. Before completing this form, read the Prior Authorization/Preferred Drug List (PA/PDL) Exemption Request Completion Instructions, F-11075A. Providers may refer to the Forms page of the ForwardHealth Portal at www.forwardhealth.wi.gov/WIPortal/Content/provider/forms/index.htm.spage for the completion instructions. Pharmacy providers are required to have a completed Prior Authorization/Preferred Drug List (PA/PDL) Exemption R.

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