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Zip: Home Phone: Alternate Phone: PRESCRIBER INFORMATION Prescriber s Name: State License #: DEA #: Group or Hospital: Address: City, State Zip: Phone: Contact Person: Primary Language: Last Four of SS #: Fax Referral To: 866-811-7450 Phone: 866-792-2731 Date of Birth: Gender: UPIN: NPI #: Fax: Phone: INSURANCE INFORMATION (Please copy and attach the front and back of insurance and prescription drug card) Prescription Card: Primary Insurance: Name of Insurer: Subscriber: ID#: ID#:.

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How do I change my HMO Primary Care Physician? Log on to our member site,Floridablue.com, and go to Account → Account Settings to change your Primary Care Physician or call the number on the back of your member ID card.

You can reach us by phone at 800-352-2583 or chat live with us by clicking Chat. Or you can call 877-352-5830 to be automatically routed to your local Florida Blue Center.

Register for your account at floridablue.com or through the Florida Blue app. It's just a few simple steps! And you can use the same username and password to log in to both places. Once you're registered, you can set up face recognition or fingerprint login through the app.

Your member number is on the front of your ID card, as shown here. Please enter your full member number (with letters and numbers). Your member number is on the front of your ID card, as shown here.

How do I submit a claim? If your provider or pharmacy is in your plan's network, they'll submit the claim for you. If you saw an out-of-network provider, you'll need to submit a medical claim form. If this was for emergency care, call us first at 800-352-2583 to see if a claim was filed.

If you have selected your plan through Florida Blue a Change Application form must be completed and signed by the primary account holder, and then submitted with a copy of the legal document(s) showing the name change (i.e., marriage certificate, divorce decree, or driver's license).

An account may be locked for technical or security reasons. Call the number on the back of your ID card and a customer service representative will unlock your account.

You can also request a copy by: Emailing 1095Breprint@floridablue.com. Sending your request in writing to Customer Service at 4800 Deerwood Campus Parkway, Jacksonville, FL 32246. Calling us at 800-352-2583.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232