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Get FL Sunshine State Health Plan Prior Authorization Fax Form 2016-2022

Equest, please contact us at 1-866-796-0530. If this is a Medicare request, please fax to 877-617-0394. * INDICATES REQUIRED FIELD Date of Birth MEMBER INFORMATION Member ID/Medicaid ID * *0675* Units Request for additional units. Existing Authorization * (MMDDYYYY) Last Name, First REQUESTING PROVIDER INFORMATION Requesting NPI * Requesting TIN * Requesting Provider Name Requesting Provider Contact Name Phone Fax SERVICING PROVIDER / FACILITY INFORMATION Same as Requesting Pro.

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