Florida Pharmacy Prior Authorization Form - Simply 2026

1. Click ‘Get Form’ to open the Florida Pharmacy Prior Authorization Form in our editor.
2. Begin by filling out the member information section. Include the last name, first name, member ID, date of birth, height, weight, and sex. Ensure all fields are completed to avoid processing delays.
3. Next, provide medication information. Enter the drug name and strength requested, dosage instructions (SIG), diagnosis or indication, and required ICD and HCPCS billing codes.
4. Indicate if the member has tried other medications for this condition. If yes, list them along with any adverse reactions or inadequate responses experienced.
5. Complete the prescriber information section with your details including NPI and DEA/license number. Ensure accuracy as this is crucial for authorization.
6. Finally, review all sections for completeness before signing at the bottom of the form. Your signature certifies that all provided information is accurate.

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