Follow the steps to successfully complete the FL SFLPEC-1302-19 form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with the member information section. Fill in the member's last name, first name, and place of residence. Indicate if the member resides at home, in a nursing facility, or another site.
3. Complete the administration site section by selecting whether it is at home or office.
4. Input the member’s MI, member ID, date of birth, height, weight, and sex by circling F or M.
5. Proceed to the medication information section. Enter the drug name and strength requested, dosage, frequency, duration, and the pertinent diagnosis or indication.
6. Enter the required HCPCS billing code and ICD code.
7. Answer the questions regarding prior medication trials. If the member has tried other medications, list them in the provided space.
8. Indicate if the member experienced any adverse reactions or inadequate responses to previous medications, using the provided options.
9. Fill in the date range of use and more specific details regarding adverse reactions or inadequate responses.
10. Describe the medical necessity for nonpreferred medications or off-label use in the specified space.
11. List all current medications with their dosages and frequencies.
12. In the diagnostic studies and laboratory tests section, document any tests performed within the last 30 days relevant to the medication requested.
13. Complete the prescriber information, ensuring to include the prescriber’s last name, first name, MI, NPI, DEA/license number, state, address, and contact information.
14. Fill out the billing facility information, including name, NPI/tax ID, address, and contact details.
15. In the pharmacy information section, provide the pharmacy name, telephone number, and fax number.
16. Finalize the form with the prescriber’s signature and date, confirming the information provided is accurate.
17. Once all sections are completed, review the form for accuracy and completeness, then save your changes.
18. Download, print, or share the form as needed.

Ensure you complete the FL SFLPEC-1302-19 form online today for your medication authorization requests.