Forms
Member forms
- Appoint representative form - grievances and appeals (PDF) Opens a new window
- Authorization for disclosure of health information (PDF) Opens a new window
- Freedom of Choice Survey for Children Receiving Private Duty Nursing (PDF) Opens a new window
- Member appeal form (PDF) Opens a new window
- Personal representative request form (PDF) Opens a new window
Provider forms
- Panel release form (PDF) Opens a new window
- Provider complaint form (PDF) Opens a new window
- Provider claim refund form (PDF) Opens a new window
Medical forms
- Authorized referral form (PDF) Opens a new window
- Continuity of care (COC) form (PDF) Opens a new window
- Resource guide (PDF) Opens a new window
- HCPCS/CPT medication prior authorization request (PDF) Opens a new window
- Informed consent for psychotherapeutic medication form (PDF) Opens a new window
- PCP increase attestation form (PDF) Opens a new window
- Prior authorization lookup tool
- Prior authorization reference guide (PDF) Opens a new window
- Prior authorization request form (PDF) Opens a new window
- WIC medical referral form (PDF) Opens a new window
Pregnancy/prenatal forms
Transportation forms
- Transportation — Level of Need Assessment Form (PDF) Opens a new window
- Transportation — Level of Need Assessment Form — Ambulance and Stretcher (PDF) Opens a new window
Behavioral health forms
- Telehealth Attestation (PDF) Opens a new window
- Behavioral Health Provider Quick Reference Guide (PDF) Opens a new window
- Behavioral Health Access to Care Provider Attestation (PDF) Opens a new window
- Behavioral Health Subspecialty Checklist (PDF) Opens a new window
- Psychological/Neuropsychological Testing Request form (PDF) Opens a new window
- Behavioral Health Fax form (PDF) Opens a new window
- Adult high dose antipsychotic (PDF) Opens a new window
- Antidepressants (<6 years of age) (PDF) Opens a new window
- Antipsychotics (<6 years of age) (PDF) Opens a new window
- Antipsychotics (Age 6 to <18 years of age) (PDF) Opens a new window
Risk management forms
- Provider adverse incident form (PDF) Opens a new window
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) Opens a new window
- Adult high dose antipsychotic (PDF) Opens a new window
- Albumin (PDF) Opens a new window
- Antidepressants (< 6 years of age) (PDF) Opens a new window
- Antipsychotics (< 6 years of age) (PDF) Opens a new window
- Antipsychotics (Age 6 to < 18 years of age) (PDF) Opens a new window
- Botox (PDF) Opens a new window
- Buprenorphine agents (PDF) Opens a new window
- Cytogam (PDF) Opens a new window
- Fuzeon (PDF) Opens a new window
- Hepatitis C agents (PDF) Opens a new window
- HIV diagnosis verification (PDF) Opens a new window
- Human growth hormone (PDF) Opens a new window
- Human growth hormone for HIV wasting in adults (Serostim) (PDF) Opens a new window
- Increlex (PDF) Opens a new window
- Miscellaneous pharmacy prior authorization requests (PDF) Opens a new window
- Multi-source brand drugs (PDF) Opens a new window
- Neupogen/Leukine/Neulasta/Granix/Zarxio (PDF) Opens a new window
- Oral oncology agents (PDF) Opens a new window
- Orfadin (PDF) Opens a new window
- Oxycodone ER (Oxycontin) (PDF) Opens a new window
- Panretin (PDF) Opens a new window
- Procrit/Aranesp (PDF) Opens a new window
- Proleukin (PDF) Opens a new window
- Provigil (PDF) Opens a new window
- Selzentry (PDF) Opens a new window
- Soma (PDF) Opens a new window
- Sovaldi kick payment (PDF) Opens a new window
- Stimulants and Strattera (< 6 years of age) (PDF) Opens a new window
- Supprelin LA (PDF) Opens a new window
- Synagis - All Florida regions combined (PDF) Opens a new window
- Synagis - Weight change (PDF) Opens a new window
- Valcyte (PDF) Opens a new window
- Vfend (PDF) Opens a new window