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Get FL SFCCN Medical Authorization Request Form 2014-2024

Er Portal: https://cms.einfosource.med3000.com One request per form - Separate approvals must be obtained for the facility and the provider. Program: Request Type: â–¡ Title XIX (T19 MMA-CMSN Plan) â–¡ Title XXI (T21) â–¡ Standard â–¡ STAT* â–¡ Retro (service already provided) â–¡ ER or Observation Stay Notification *Standard timeframe could seriously jeopardize the member's life, health, or ability to obtain, maintain, or regain maximum function. Member: __________________________ DOB: _____.

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