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Get and Sign Medicaid Authorization Florida Form
Birth:
Formula constitutes _________% of recipients’ daily nutrition
Qualifying diagnosis:
□
Administer by tube
□
Projected length of therapy (0-6 months):
Administer orally
Diagnosis Code (ICD-9):
Treating physician: _______________________________ License #: _________________ Medicaid ID #: ___________________ NPI#: ______________
(Print)
Address: ______________________________________________________City: __________________________ State: ________ Zip: ______________
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