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Get Sunshine Inpatient Authorization Form 2015-2024

ID/Medicaid ID * *0676* This is a standard authorization request that may take up to 7 calendar days to process. If this is an expedited request, please contact us at 1-866-796-0530. If this is a Medicare Request, please fax to 877-617-0394. * (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.

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