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Florida Department of State and Division of Library and Information Services

Notice: 19983084

Final Adopted Version in F.A.C.

Department:

AGENCY FOR HEALTH CARE ADMINISTRATION

Division:

Chapter:

GENERAL MEDICAID

Overview

RULE:

Medicaid Forms

RULE FILE DATE:

1/19/2018

RULE EFFECTIVE DATE:

2/8/2018

HISTORY NOTES:

Rulemaking Authority 409.919 FS. Law Implemented 409.902, 409.905, 409.912 FS. History–New 9-28-15, Amended 7-11-16, 4-5-17, 2-8-18.

OVERSIGHT COMMITTEE:

Joint Administrative Procedures Committee
Florida Administrative Law Central Online Network (F.A.L.C.O.N.)

RELATED COURT CASES:

Division of Administrative Hearings

FEDERAL RULES
AND REGULATIONS:

Electronic Code of Federal Regulations

HOW TO LINK TO
THIS NOTICE:

http://flrules.org/gateway/ruleno.asp?id=59G-1.045&Section=0

REFERENCE MATERIALS:

Ref-07012 Medical Certification for Medicaid Long-term Care Services and Patient Transfer, AHCA Form 5000-3008
Ref-07013 State of Florida Abortion Certification Form, AHCA MedServ Form 011
Ref-07014 State of Florida Exception to Hysterectomy Acknowledgment Requirement, ETA-5001
Ref-07015 State of Florida Hysterectomy Acknowledgment Form, HAF-5000
Ref-07915 Unborn Activation Form, AHCA Form 5240-006, February 2017
Ref-07926 The United States Department of Health and Human Services’ Consent for Sterilization Form - HHS-687 (10/12) (Consent for Sterilization Form)
Ref-09057 Acquired Immune Deficiency Syndrome (AIDS) Physician Referral for Individuals at Risk of Hospitalization, AHCA Form 5000-0607, January 2018
Ref-09058 Adults with Cystic Fibrosis Physician Referral for Individuals at Risk of Hospitalization, AHCA Form 5000-0608, January 2018
Ref-09059 Consent for Voluntary Suspension of Authorized Services for Florida Medicaid State Plan Recipients, AHCA Form 5000-0123, August 2017
Ref-09060 Model Waiver Physician Referral for Individuals at Risk of Hospitalization, AHCA Form 5000-0025, January 2018

Under Florida law, E-mail addresses are public records. If you do not want your E-mail address released in response to a public records request, do not send electronic mail to this entity. Instead, contact this office by phone or in writing.