Member Grievance

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

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Provider Complaint

Send this form with all documentation to support the complaint

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Abortion Certification

State of Florida Abortion Certification Form

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End Stage Renal Disease

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

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Hospice Prior Authorization Request

Hospice Prior Authorization Request Form

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Pregnancy Notification Form

Pregnancy Notification Form

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Prenatal Notification

Prenatal Notification Form

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Sterilization Consent

State of Florida Sterilization Consent Form

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Transplant Authorization Request Form

Save time! Submit and review your requests online @ https://provider.wellcare.com

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Staywell Transportation Authorization Request Form

Requirements: Clinical information and supportive documentation should consist of current physician order, notes and recent diagnostics. Notification is required for any date of service change.

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Detox and Substance Abuse Rehab Service Request

Florida Medicaid Behavioral Health Services Request Form for Detox and Substance Abuse Rehab Services

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Florida Medicaid Routine Outpatient Services

Florida Medicaid Behavioral Health Services Request Form for Routine Outpatient Services

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PHP and Intensive Outpatient Services Request

Florida Medicaid Behavioral Health Services Request Form for Intensive Outpatient and PHP Services

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Residential, SIPP and Specialized Therapeutic Services Request

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

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NDC Reporting Guidelines

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

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UB-04 Submission Sample

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.

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Immunization Record

This is a form for keeping a record of immunizations.

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Medication Profile

This is a form for recording a Medication Profile

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Food Supplement Request Form

Request form for food supplements

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Hepatitis C Treatment Prior Authorization Form

Prior authorization request form for Hepatits C Treatment.

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Medicaid Coverage Determination Request

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

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Chlamydia Screening Flyer

Chlamydia is the most common sexually transmitted bacterial infection (STI) in the United States. The best way to detect chlamydia in its early stages is to conduct screenings at yearly physicals for patients who are sexually active.

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Diabetes Standard of Care Tracking

This is a form for the Diabetes Standard of Care Tracking

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Exception to Hysterectomy Acknowledgement

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

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Florida's Healthy Start Prenatal Risk Screening (DH3134)

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

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WIC Program Medical Referral (DH3075)

Florida WIC Program Medical Referral Form

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