Florida Medicaid Prior Authorization

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FLORIDA MEDICAID PRIOR AUTHORIZATION
Stimulants and Strattera (<6 years of age)
Please select all that apply:
High-dose stimulant
Long-acting stimulant
Strattera
Maximum length of approval = 6 months or less
Note: Form must be completed in full. An incomplete form may be returned.
Adde
Recipient’s Medicaid ID#
Date of Birth (MM/DD/YYYY)
/
/
Recipient’s Full Name
Prescriber’s Full Name
Prescriber License # (ME, OS, ARNP, PA)
Prescriber Phone Number
Prescriber Fax Number
-
-
-
-
New
Continuation:
Same dose
Increase
Decrease
Is child in state custody care?
No
Yes
Drug: _____________________________ Dose: _________ Frequency: _____________________ Quantity: _________
Request ____months therapy Diagnosis:
____________Target Symptoms: _________________________
ADHD
Other
Comorbid Medical and Psychiatric Diagnoses:______________________________________________________________
Height: _________ in / cm
Weight: ___________ lbs /kgs
Blood Pressure: _______________ Pulse: ____________
BMI% ___________ History of cardiovascular disease?
No
Yes; If yes,
patient, or
family
Previous Behavioral Interventions (duration with date of initiation; if discontinued, include date and reason): _____________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Previous Medication Therapy (include drug name, dose, trial duration, and reason for discontinuation): _________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
List other medications to be taken with the requested stimulant medication or Strattera: _________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Does the patient swallow medications whole (e.g., necessary for Concerta and Strattera)?
Yes
No
Prescriber’s Signature _____________________________________________
Date: _____________________________
REQUIRED FOR REVIEW: Copies of medical records (i.e., diagnostic evaluations and recent chart notes), a copy of the original prescription,
and the most recent copies of related labs. The provider must retain copies of all documentation for five years.
Mail or Fax Information to:
University of South Florida, School of Medicine, Department of Psychiatry
Magellan Medicaid Administration, Inc.
USF Child Psychiatrist Review:
Prior Authorization
P. O. Box 7082
I do not recommend approval ____________
I recommend approval for _______ months
Tallahassee, FL 32314-7082
Phone: 877-553-7481
USF Child Psychiatrist Signature:_____________________________
Date: ___________
Fax: 877-614-1078

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