Durable Medical Equipment
(DME), Home Health & Home
Infusion Referral Form
Standard Request Fax to 866-534-5978
Monday through Friday 8am – 5pm
Hospital Discharges Fax to 844-801-8413
Please fax this completed form along with associated clinical information or medical records to Sunshine
Health. Lack of clinical information may result in delayed determination.
*Indicates Required Field
*Member First Name: *Member Last Name:
*Member ID #: *Member Date of Birth:
*Member Home Address: *Service Address (if diﬀerent from home):
*Member Phone Number: Alternative Contact Person:
Relationship to Member:
Alternative Contact Phone Number:
Member Height (in inches): Member Weight (in pounds):
Requesting Provider Information
m New Request m Extension Request Date member last seen by requesting provider:
Requesting Provider NPI: Requesting Provider TIN:
*Requesting Provider Name: Requesting Provider Contact Name:
*Phone Number: *Fax Number:
m Check here if this request is related to an
*If a Discharge, Date of Discharge:
*Primary Diagnosis Code: *Start Date of Service:
Additional Diagnosis Code: End Date of Service:
Number of Total Units/Visits/Days Requested:
Information on services that require a prior authorization can be found at www.SunshineHealth.com. For questions please call Sunshine
Health’s Utilization Management Department at () - and select the prompt for home care or DME. We are open from a.m.
to p.m. Monday through Friday.
Last Updated 3/23/2017
© 2017 Sunshine State Health Plan. All rights reserved.