Sunshine Health Id Printout Form PDF Details

The Sunshine Health Id Printout Form is an important document when applying for health insurance, especially in the state of Florida. Not only can it help you get access to health care coverage, but it's also a useful tool for verifying your identity and helping you manage your medical bills. In this blog post, we'll tell you all about the importance of having a Sunshine Health Id Printout Form and how to obtain one. We’ll also explain what the form looks like, its various uses, as well as recommendations on where best to store it once you receive one. So let's dive right in and learn more about this essential documentation!

QuestionAnswer
Form NameSunshine Health Id Printout Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namessunshine pa form, bs of ca promise health plan pa form, sunshine prior authorization form, sunshine health pa form

Form Preview Example

OUTPATIENT

Complete and Fax to: 1-866-796-0526

Prior Authorization Fax Form

This is a standard authorization request that may take up to 14 days to process. If this is an urgent/stat request, please contact us at 1-866-796-0530.

Request for additional units. Existing Authorization

Units

*INDICATES REQUIRED FIELD

 

 

 

 

 

Date of Birth *

MEMBER INFORMATION

 

 

 

Member ID/Medicaid ID *

 

(MMDDYYYY)

 

Last Name, First

REQUESTING PROVIDER INFORMATION

 

Requesting NPI *

Requesting TIN *

Requesting Provider Contact Name

*0322*

Requesting Provider Name

Phone

Fax

SERVICING PROVIDER / FACILITY INFORMATION

Same as Requesting Provider

Servicing NPI *

 

Servicing TIN*

 

Servicing Provider Contact Name

Servicing Provider/Facility Name

Phone

 

Fax

 

 

 

AUTHORIZATION REQUEST

 

 

 

 

Primary Procedure Code *

Start Date OR Admission Date

*

Diagnosis Code

*

(CPT/HCPCS)

(Modiier)

(MMDDYYYY)

 

(ICD-9)

 

Additional Procedure Code

End Date OR Discharge Date

 

Total Units/Visits/Days

(CPT/HCPCS)

(Modiier)

(MMDDYYYY)

 

 

 

OUTPATIENT SERVICE TYPE *

(Fill in the square with an X)

Auditory Services

Hospital Outpatient Surgery

 

Office Visit

Observation

 

Other Site

OB Ultrasound

Dialysis (Non Par Only)

Office Visit

 

Genetic Testing

Other Site

 

Global OB Care

Oice Visit (non-participating)

Office Visit

Office Visit

 

Other Visit

Other Site

Orthotics and Prosthetics

Transplants (Evals and Consults)

(If purchase price greater

 

than $500)

Office Visit

Pain Management

Other Visit

 

Office Visit

 

 

Transportation

Other Site

(Non-emergency)

 

Rehab (OT/PT/ST)

Please contact NIA for Radiology Services. Please contact Univita for DME and Home Health Care services.

ALL REQUIRED FIELDS MUST BE FILLED IN AS INCOMPLETE FORMS WILL BE REJECTED.

COPIES OF ALL SUPPORTING CLINICAL INFORMATION ARE REQUIRED. LACK OF CLINICAL INFORMATION MAY RESULT IN DELAYED DETERMINATION.

Disclaimer: An authorization is not a guarantee of payment. Member must be eligible at the time services are rendered. Services must be a covered Health Plan Beneit and medically necessary with prior authorization as per Plan policy and procedures.

Confidentiality: The information contained in this transmission is conidential and may be protected under the Health Insurance Portability and Accountability Act of 1996.

 

If you are not the intended recipient any use, distribution, or copying is strictly prohibited. If you have received this facsimile in error, please notify us immediately and

FL-PAF-0322

destroy this document.

How to Edit Sunshine Health Id Printout Form Online for Free

sunshine health pa form can be filled in in no time. Simply use FormsPal PDF tool to perform the job fast. The tool is consistently improved by us, getting new awesome features and becoming a lot more convenient. To begin your journey, consider these basic steps:

Step 1: Press the orange "Get Form" button above. It'll open up our editor so you can start filling in your form.

Step 2: As soon as you open the tool, you will find the form all set to be filled in. Aside from filling out various fields, you might also do several other things with the form, that is writing your own text, changing the original textual content, inserting graphics, affixing your signature to the form, and a lot more.

As a way to finalize this document, be sure to type in the information you need in every area:

1. Before anything else, when filling out the sunshine health pa form, start out with the form section that has the following fields:

Filling out part 1 of sunshine state helath plan medicaid prior authorization form

2. After the last segment is done, you're ready to include the required particulars in Servicing NPI, Servicing TIN, Servicing Provider Contact Name, Servicing ProviderFacility Name, Phone, Fax, AUTHORIZATION REQUEST, Primary Procedure Code, Start Date OR Admission Date, Diagnosis Code, CPTHCPCS, Modiier, MMDDYYYY, ICD, and Additional Procedure Code so you're able to proceed further.

Find out how to prepare sunshine state helath plan medicaid prior authorization form portion 2

3. This next step is going to be hassle-free - complete every one of the fields in ALL REQUIRED FIELDS MUST BE FILLED, COPIES OF ALL SUPPORTING CLINICAL, Disclaimer An authorization is not, FLPAF, Please contact NIA for Radiology, Global OB Care, Office Visit, Other Visit, Oice Visit nonparticipating, Office Visit, Other Site, and Rehab OTPTST to conclude this segment.

Part # 3 for submitting sunshine state helath plan medicaid prior authorization form

People who use this document often make some errors when filling out Disclaimer An authorization is not in this part. Make sure you review whatever you enter here.

Step 3: Prior to finalizing your form, double-check that all blanks are filled in right. Once you believe it's all good, press “Done." Sign up with FormsPal now and easily access sunshine health pa form, all set for download. All modifications made by you are preserved , enabling you to edit the pdf at a later time if required. With FormsPal, you'll be able to complete forms without being concerned about data breaches or records getting shared. Our secure platform ensures that your private details are kept safe.

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