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Provider Forms

Authorization Forms

Behavioral Health – Prior Authorization Form

General Rx – Prior Authorization Form

Medical Services – Prior Authorization Form

Radiology Authorization Online Form

Residential Psychiatric Treatment Authorization Form

Synagis – Weight Change/Prior Authorization Form

Medical Forms

Adult Health Assessment Form

Child Health Assessment Form

Request Form for Multi-Source Brand Drug

SIPP/STGC Discharge Notification Form

Health Information Forms

AUD Consent Form (Ongoing sharing of information)

AUD Consent Form (Release for specific information)

Appeals Forms

Provider Appeal Form

Prescription Drug Forms

Antidepressants – Under 6 years of age

Antipsychotic – Under 6 years of age

Antipsychotic – 6 to under 18 years of age

Adult Antipsychotic- High dose

Human Growth Hormone Diagnosis

Multi-source brand

Neupogen Leukine Neulasta Diagnosis

For Magellan Complete Care of Florida Pharmacy prior authorizations, please fax or mail completed forms to:

Magellan Complete Care of Florida
c/o Magellan Pharmacy Solutions
11013 West Broad Street
Suite 500
Glen Allen, VA 23060

Fax: 800-424-7982
Phone: 800-327-8613 (TTY 711)