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Florida - Provider Manual Forms
This page is a repository of forms listed by function. The information is intended for use by Florida providers. Documents related to Member Services are included for reference only. If you have questions, please contact Customer Service at (800) 278-0656 (HealthEase), (800) 278-8178 (HealthEase Kids), (866) 334-7927 (Staywell), (866) 698-5437
(Staywell Kids) or (888) 888-9355 (Medicare).
(Staywell Kids) or (888) 888-9355 (Medicare).
Administrative Review
- Appointment of Representative Form (Medicare)
- Appointment of Representative Form (Non-Medicare)
- Member Appeal Request Form
- Member Grievance Form (Medicaid)
- PCP Request for Transfer of Member
- Provider Appeal Request Form
- Provider Complaint Form
Authorizations
- Abortion Certification Form
- Ancillary Services Authorization Request Form (Medicaid)
- Ancillary Services Authorization Request Form (Medicare)
- Delegated Vendor Authorization Request (Medicare)
- End Stage Renal Disease Form
- Hospice / ESRD Placement Referral Report
- Hysterectomy Acknowledgment Form
- Exception to Hysterectomy Acknowledgement Form
- Inpatient Authorization Request Form (Medicaid)
- Inpatient Authorization Request Form (Medicare)
- Notification/Authorization Form (Medicare)
- Outpatient Authorization Request Form (Medicaid)
- Outpatient Authorization Request Form (Medicare)
- Prenatal Notification Form
- Sterilization Consent Form
Claims
- CMS 1500 Submission Guidelines
- CMS 1500 Submission Sample
- UB-04 Guidelines for Paper Claims
- UB-04 Submission Sample
Living Will
- Designation of Health Care Surrogate (English Form)
- Designation of Health Care Surrogate (Spanish Form)
Medical Records
- Care Management Referral Form
- Child Health Check-up Forms
- Immunization Record
- Incident Report
- Medication Profile
- Problem List
Pharmacy Services
- Accu-Check® Meter Fax Order Form
- Bayer Meter Request Fax Order Form
- End Stage Renal Disease Form
- Medicaid Coverage Determination Request
- Food Supplement Request Form
- Injectable Infusion Prior Authorization Form
- Medicare Coverage Determination Request
- Synagis Order Form
- Xenical Drug Evaluation Review Form
- Xolair Request Form
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