Below is a list of Forms that may assist you in providing FCA Members with their Care.

Benefit Forms

• Enhanced Benefits Form (Eng) | (Spanish) 

Disenrollment Forms / Transfer Forms

• Disenrollment -Voluntary Disenrollment (Address, Death, Ineligible or Other Insurance Primary)

• Disenrollment - Involuntary Disenrollment Form (Behavioral)

• Member Verbal Warning Form (Behavioral)

Member Forms

• Member Grievance and Appeals Forms

• Member Change Information Form

• Member Privacy Notice

• Member Release of Medical Information

• Transportation Bus Certification Form

Miscellaneous / Provider Forms

• Credentialing Application Request Form

• Diagnostic Code List for Pregnant Women

• Expectant Mother Notification Form

• FCA On-Line Status Access Form

• Non-Par Provider Registration Form

• Provider Complaint Form (Non-Claims Issue)

• Provider Update Request Form

• Shands Jax Lab Access Form

• VFC Annual Documentation Form

Pre-Authorization

• Adult Dermatology Consultation Form

• Behavioral Health Pre-Authorization/Notification Form

• Behavioral Health Additional Units Form 

• Behavioral Health Discharge Information Form

• Behavioral Health Inpatient Continued Stay Form

• Medical Pre-Authorization Form

• FCA ON-LINE STATUS
• TRAINING MODULE
• ABOUT US
• EDUCATION
• FCA DISASTER PLAN
• MEMBER INFORMATION
• CONTACT US (MEMBERS)
• FIND A PHYSICIAN
• PREFERRED DRUG LIST
• FAQ
• NEWSLETTER/NEWSFLASH
• PRE-AUTHORIZATION
• PROVIDER INFORMATION
• LINKS
• IMPORTANT PHONE LISTS
• IN-SERVICE INFORMATION
• INTERESTED PROVIDERS
• SERVICE ALERTS

 

 

 

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