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Get Sunshine State Health Plan FL-PAF-0322

Ase contact us at 1-866-796-0530. Units * INDICATES REQUIRED FIELD Date of Birth MEMBER INFORMATION Member ID/Medicaid ID * *0322* Request for additional units. Existing Authorization * (MMDDYYYY) Last Name, First REQUESTING PROVIDER INFORMATION Requesting NPI * Requesting TIN * Requesting Provider Contact Name Requesting Provider Name Phone Fax SERVICING PROVIDER / FACILITY INFORMATION Same as Requesting Provider Servicing NPI * Servicing TIN * Servicing Provider/Facility .

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