Fla. Admin. Code Ann. R. 59G-1.045 - Medicaid Forms

The following forms are incorporated by reference and are used either by other state agencies or providers rendering Florida Medicaid services to recipients. The forms are available from the Agency for Health Care Administration's Web site at http://ahca.myflorida.com/Medicaid/review/index.shtml.

(1) Acquired Immune Deficiency Syndrome (AIDS) Physician Referral for Individuals at Risk of Hospitalization, AHCA Form 5000-0607, January 2018, http://www.flrules.org/Gateway/reference.asp?No=Ref-09057.

(2) Adults with Cystic Fibrosis Physician Referral for Individuals at Risk of Hospitalization, AHCA Form 5000-0608, January 2018, http://www.flrules.org/Gateway/reference.asp?No=Ref-09058.

(3) Consent for Voluntary Suspension of Authorized Services for Florida Medicaid State Plan Recipients, AHCA Form 5000-0123, August 2017, http://www.flrules.org/Gateway/reference.asp?No=Ref-09059.

(4) Medical Certification for Medicaid Long-term Care Services and Patient Transfer Form, AHCA Form 5000-3008, June 2016, http://www.flrules.org/Gateway/reference.asp?No=Ref-07012.

(5) Model Waiver Physician Referral for Individuals at Risk of Hospitalization, AHCA Form 5000-0025, January 2018, http://www.flrules.org/Gateway/reference.asp?No=Ref-09060.

(6) State of Florida Abortion Certification Form, AHCA MedServ Form 011, June 2016, http://www.flrules.org/Gateway/reference.asp?No=Ref-07013.

(7) State of Florida Exception to Hysterectomy Acknowledgment Requirement, ETA-5001, June 2016, http://www.flrules.org/Gateway/reference.asp?No=Ref-07014.

(8) State of Florida Hysterectomy Acknowledgment Form, HAF-5000, June 2016, http://www.flrules.org/Gateway/reference.asp?No=Ref-07015.

(9) The United States Department of Health and Human Services' Consent for Sterilization Form - HHS-687 (10/12), http://www.flrules.org/Gateway/reference.asp?No=Ref-07926.

(10) Unborn Activation Form, AHCA Form 5240-006, (February 2017), http://www.flrules.org/Gateway/reference.asp?No=Ref-07915.

Notes

Fla. Admin. Code Ann. R. 59G-1.045

Rulemaking Authority 409.919 FS. Law Implemented 409.902, 409.905, 409.912 FS.

Adopted by Florida Register Volume 41, Number 179, September 15, 2015 effective 9/28/2015, Amended by Florida Register Volume 42, Number 125, June 28, 2016 effective 7/11/2016, Amended by Florida Register Volume 43, Number 055, March 21, 2017 effective 4/5/2017, Amended by Florida Register Volume 44, Number 015, January 23, 2018 effective 2/8/2018.

New 9-28-15, Amended 7-11-16, 4-5-17, 2-8-18.