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Florida medicaid authorization form 2026

The document is an authorization request form for enteral formula, intended for use by physicians, WIC nutritionists, and DME providers. It includes sections for physician certification, WIC program verification, and DME provider details. The form requires information about the recipient's medical condition, nutritional needs, and the specific enteral formula requested. It also outlines the process for calculating units of formula needed based on caloric intake and provides instructions for submission to ensure proper authorization from Medicaid.

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Begin with Part 1, where the physician must complete the Recipient ID number, name of the enteral formula ordered, and recipient details such as height, weight, age, and date of birth.
Indicate the qualifying diagnosis and provide the appropriate ICD-9 code. Specify how the formula will be administered (by tube or orally) and project the length of therapy.
In Part 2, if applicable, have a WIC Nutritionist complete their section by detailing the amount of enteral formula provided by WIC and what is requested from Medicaid.
Finally, in Part 3, ensure that the DME provider fills out their information including provider name, number, procedure code, and signature before submitting it for review.

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