Get Florida Blue Prior Authorization Form Pdf

Filling out the Florida Blue Prior Authorization Form Pdf can be a straightforward process when you understand each section clearly. This guide provides step-by-step instructions to assist you in completing the form correctly and efficiently.

Follow the steps to fill out the Florida Blue Prior Authorization Form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Complete the policy holder information section. Enter the policy holder's name, member ID number, group number, date of birth, street address, city, state, zip code, and select their sex.
3. If applicable, fill in the patient information section. This includes the patient's name, date of birth, address (if different), select their sex, and indicate the relationship to the policy holder.
4. Complete the general information section. Indicate if the condition was related to an accident, providing details if necessary, and specify if other insurance is applicable to the charge.
5. In the pharmacy information section, enter the pharmacy name, NCPDP number, street address, NPI number, phone number, city, state, zip code, pharmacist's signature, and license number.
6. Provide the required prescription information. Ensure that prescription receipts are attached and that they include all necessary details such as patient name, pharmacy name and address, total charge, and more.
7. Finally, sign the certification section, confirming that all information provided is true and correct. Indicate the date of signing.
8. Once all sections are filled out, you can save your changes, download, print, or share the completed form as needed.

Complete your Florida Blue Prior Authorization Form online today for a smooth submission process.