• Referral Authorization
• Prior Authorization
  • Procedures and Services Requiring Prior Authorization (PA Grid)
  • Senior Preferred Part B therapies exceeding 30 visits
• Wheelchair Rental
• Functional Mobility Assessment 

Senior Preferred Forms

• Detailed Notice of Discharge
• Inpatient Medicare Discharge Rights
• Important Medicare Message of Non-Coverage
• Notice of Medicare Non-coverage: Home Health
• Notice of Medicare Non-coverage: Skilled Nursing Facility
• Notice of Denial of Medical Coverage: Skilled Nursing Facility Admission
  • What is this Notice?
• Notice of Denial of Medical Coverage: Hospital Observation Level of Care
  • What is this Notice?

Pharmacy Forms

• Employer Group Drug Prior Authorization
• Senior Preferred Part D Prior Authorization Request
• Pharmacy and Therapeutic Committee: Formulary Review Grid
• Pharmacy and Therapeutic Committee: Formulary Request for Review

Completed forms should be sent to:

Gundersen Lutheran Health Plan
1836 South Avenue, Mail Stop: NCA2-01
La Crosse, WI 54601 or faxed to the number on the form.