Forms
Member forms
- Appoint representative form - grievances and appeals (PDF)
- Authorization for disclosure of health information (PDF)
- Freedom of Choice Survey for Children Receiving Private Duty Nursing (PDF)
- Member appeal form (PDF)
- Personal representative request form (PDF)
Provider forms
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
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)