Forms

Member forms

• Appoint representative form - grievances and appeals (PDF)
• Authorization for disclosure of health information (PDF)

• Freedom of Choice Certification for Children in Nursing Facilities (PDF)

• Freedom of Choice Survey for Children Receiving Private Duty Nursing (PDF)
• Member appeal form (PDF)
• Personal representative request form (PDF)

Provider forms

• Panel release form (PDF)
• Provider complaint form (PDF)
• Provider claim refund form (PDF)

Medical forms

• Authorized referral form (PDF)
• Continuity of care (COC) form (PDF)
• Resource guide (PDF)
• HCPCS/CPT medication prior authorization request (PDF)
• Informed consent for psychotherapeutic medication form (PDF)
• PCP increase attestation form (PDF)
• Prior authorization lookup tool
• Prior authorization reference guide (PDF)
• Prior authorization request form (PDF)
• WIC medical referral form (PDF)

Pregnancy/prenatal forms

• Florida Medicaid Pregnancy Notification Form (PDF)
• Prenatal risk screen form (PDF)

Transportation forms

• Transportation — Level of Need Assessment Form (PDF)
• Transportation — Level of Need Assessment Form — Ambulance and Stretcher (PDF)

Behavioral health forms

• Telehealth Attestation (PDF)
• Behavioral Health Provider Quick Reference Guide (PDF)
• Behavioral Health Access to Care Provider Attestation (PDF)
• Behavioral Health Subspecialty Checklist (PDF)
• Psychological/Neuropsychological Testing Request form (PDF)
• Behavioral Health Fax form (PDF)
• Adult high dose antipsychotic (PDF)
• Antidepressants (<6 years of age) (PDF)
• Antipsychotics (<6 years of age) (PDF)
• Antipsychotics (Age 6 to <18 years of age) (PDF)

Risk management forms

• Provider adverse incident form (PDF)
  Complete this form to report adverse incidents or injuries that affect AmeriHealth Caritas Florida members.

Pharmacy prior authorization forms

• Abstral/Actiq/Fentora/Lazanda/Onsolis/Subsys (PDF)
• Adult high dose antipsychotic (PDF)
• Albumin (PDF)
• Antidepressants (< 6 years of age) (PDF)
• Antipsychotics (< 6 years of age) (PDF)
• Antipsychotics (Age 6 to < 18 years of age) (PDF)
• Botox (PDF)
• Buprenorphine agents (PDF)
• Cytogam (PDF)
• Fuzeon (PDF)
• Hepatitis C agents (PDF)
• HIV diagnosis verification (PDF)
• Human growth hormone (PDF)
• Human growth hormone for HIV wasting in adults (Serostim) (PDF)
• Increlex (PDF)
• Miscellaneous pharmacy prior authorization requests (PDF)
• Multi-source brand drugs (PDF)
• Neupogen/Leukine/Neulasta/Granix/Zarxio (PDF)
• Oral oncology agents (PDF)
• Orfadin (PDF)
• Oxycodone ER (Oxycontin) (PDF)
• Panretin (PDF)
• Procrit/Aranesp (PDF)
• Proleukin (PDF)
• Provigil (PDF)
• Selzentry (PDF)
• Soma (PDF)
• Sovaldi kick payment (PDF)
• Stimulants and Strattera (< 6 years of age) (PDF)
• Supprelin LA (PDF)
• Synagis - All Florida regions combined (PDF)
• Synagis - Weight change (PDF)
• Valcyte (PDF)
• Vfend (PDF)