Nursing & Care Request Form

One form for every request — facilities, physician practices, specialty pharmacies and infusion centers, hospices, and families. Complete it and we will identify the appropriate Florida-licensed nurse, certified nursing assistant, home health aide, or companion for your patient or setting. You can also reach us directly — Phone: (941) 248-3816 or Fax: (239) 376-1509. Please do not include detailed protected health information (PHI) in this form — a member of our team will reach out by phone to gather clinical information securely.

A. Requester Information

B. Coverage Request

Skilled Nursing & Facility Support
Infusion & Vascular Access
Gulfside serves AHCA Region 8 — Lee, Charlotte, Collier, Sarasota, Hendry, Glades, and DeSoto counties.

C. Contractor Requirements

D. Patient / Client Information (general only — no PHI)

1000 character limit — please do not include PHI.

E. Billing / Authorization

F. Additional Comments or Special Instructions

2000 character limit.

Consents

Thank you — we received your request.

An RN reads every one of these, and we will tell you honestly what we can cover and what we cannot.
Phone: (941) 248-3816  ·  Fax: (239) 376-1509