59G-1.045 : Medicaid Forms - Florida Administrative Rules, Law, Code, Register

Florida Department of State and Division of Library and Information Services

Rule: 59G-1.045 Prev Up Next

Rule Title: Medicaid Forms
Department:	AGENCY FOR HEALTH CARE ADMINISTRATION	Add to MyFLRules Favorites
Division:	Medicaid
Chapter:	GENERAL MEDICAID

Latest version of the final adopted rule presented in Florida Administrative Code (FAC):

	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.
	References in this version:	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

History of this Rule since Jan. 6, 2006

Section	Description	ID	Publish Date

Final 59G-1.045	Medicaid Forms	19983084	Effective: 02/08/2018
Final 59G-1.045	Medicaid Forms	18753415	Effective: 04/05/2017
Final 59G-1.045	Medicaid Forms	17691265	Effective: 07/11/2016
Final 59G-1.045	Medicaid Forms	16479347	Effective: 09/28/2015

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.