Follow the steps to effectively complete the form online.

1. Click the ‘Get Form’ button to access the form and open it in your preferred digital platform or editor.
2. Begin by filling in the requestor/contact information section. Provide your name, facility name, and direct contact telephone number clearly.
3. Next, move to the member information section. Here, include the member's name (last name, first name) and date of birth.
4. In the medical records section, indicate which records the fax information pertains to by checking the appropriate box (Florida Medicaid Transition of Care, Other, etc.).
5. Provide the fax number where the request is being sent, along with the inpatient or outpatient status, and select if it relates to behavioral health or primary health.
6. Enter the member number or Medicaid ID, along with the diagnosis code and CPT codes as required. Ensure to attach any relevant clinical documentation.
7. Proceed to the provider information section. Fill in your name, gender, date of birth, individual NPI, Medicaid ID, UPIN/Medicare number, license number, license type, specialty, and service address.
8. Continue with the billing information section, providing your TIN, group name (if applicable), billing NPI, and billing Medicaid ID (if applicable). Fill in the billing address, city, state, and zip code.
9. Once all sections are complete, review the information for accuracy. After finalizing, you can save changes, download, print, or share the filled-out form.

Complete the necessary forms online to ensure timely and efficient processing.