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Forms

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Forms

Access key forms for authorizations, claims, pharmacy and more.

Administrative Review

Non-Medicare Member Appointment of Representative Statement Form

Please use this form or a separate letter for information needed for the review of your grievance.

This form is to be used when you want to appeal a claim or authorization denial.

Send this form with all documentation to support the complaint

Complete this request in its entirety and attach all supporting documentation, including pertinent medical records and office notes.

Complete this request in its entirety and attach all supporting documentation, including pertinent medical records and office notes.

Authorizations

State of Florida Abortion Certification Form

Informed Consent for Psychotherpeutic Medication

DME Ancillary Services Authorization Request Form

End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration Form

State of Florida Physicians Certification Statement for Exception to Hysterectomy Acknowledgement Requirement

Home Health Services Authorization Request Form

Acknowledgment of Receipt of Hysterectomy Information

Inpatient Authorization Request Form

Outpatient Authorization Request Form

Prenatal Notification Form

Skilled Therapy Services (OT/PT/ST) Prior Authorization Form

State of Florida Sterilization Consent Form

Behavioral Health

Behavioral Health Service Request Form for Electroconvulsive Therapy Services

Behavioral Health Service Request Form

Florida Medicaid and Healthy Kids Behavioral Health Services Request Form for Inpatient, CSU, Detox and PHP Services

Florida Medicaid and Healthy Kids Behavioral Health Services Request Form for Intensive Outpatient and Routine Outpatient Therapy Services

Behavioral Health Service Request Form for Psychological and Neuropsychological Testing

Florida Medicaid and Healthy Kids Behavioral Health Services Request Form for Residential, SIPP, and Specialized Therapeutic Services

Claims

Example of CMS 1500 Submission

An NDC is required for pharmaceuticals that are dispensed from a pharmacy and physician-administered drugs in an office/clinic or outpatient facility/hospital setting

Providers are encouraged to submit claims with the correct taxonomy code consistent with the provider’s specialty and services being rendered in order to increase appropriate adjudication.

Please refer to NUBC (National Uniform Billing Committee – UB-04 forms) for complete detailed information about paper claim submission” and refer to the 837 Institutional Implementation Guide by Washington Publishing Company (May 2006) for any EDI related issues.

Medical Records

1 to14 Day Child Health CheckUp Tracking Form

This is a form for keeping a record of immunizations.

This Incident Report Form is used to report adverse incidents or injuries that occur to members.

This is a form for recording a Medication Profile

This is a from for recording a list of problems

Pharmacy

Request form for food supplements

Prior authorization request form for Hepatits C Treatment.

This form is used to determine coverage for prior authorizations, non-formulary medications, and medications with utilization management rules.

Fill out this form for a Medicaid Medication Appeal Request

WellCare will evaluate the request based on applicable medical criteria, FDA guidelines, protocols developed by the WellCare Pharmacy & Therapeutics Committee, and plan benefits.

Synagis® Prior Authorization Request Form for Respitory Syncytial Virus (RSV)

This is a Prior Authorization Request Form for Xolair

This form is a prior authorization for zubsolv treatment.

Other Provider Forms

This is a form for the Diabetes Standard of Care Tracking

Complete the following information to report the suspect or diagnosis of a disease which is reportable under Florida Administrative Code 64D-3.

Have a member answer the following questions to find out if anything in their life could affect their health

Pursuant to § 383.14(1)(b) and 383.011(1)(e), F.S., this form must be completed for each infant and submitted to the local County Health Department, Office of Vital Statistics.

Florida WIC Program Medical Referral Form


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Last Updated On: 4/24/2017