93-002721RX Healthplan Southeast, Inc. vs. Agency For Health Care Administration Status: Closed DOAH Final Order on Friday, November 19, 1993.

Summary: Rule requirement of 30-minute access to primary care delivery site and general hospital upheld as valid.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

HEALTHPLAN SOUTHEAST, INC., )

)

Petitioner, )

)

vs. ) CASE NO. 93-2721RX

)

AGENCY FOR HEALTH CARE )

ADMINISTRATION, )

)

Respondent. )

______________________________)

FINAL ORDER

Upon due notice, this cause came on for formal hearing on August 25, 1993

in Tallahassee, Florida, before Ella Jane P. Davis, a duly assigned hearing

officer of the Division of Administrative Hearings.

APPEARANCES

For Petitioner: John C. Pelham, Esquire

Pennington, Haben, Wilkinson, Culpepper,

Dunlap, Dunbar, Richmond, and French, P.A.

Post Office Box 13527

Tallahassee, Florida 32317-3527

For Respondent: Michael O. Mathis, Esquire

Agency for Health Care Administration

325 John Knox Road, Suite 301

The Atrium Building

Tallahassee, Florida 32303

STATEMENT OF THE ISSUE

Whether or not existing rule 59A-12.006(3)(d) F.A.C., the Health

Maintenance Organization (HMO) rule, constitutes a valid agency exercise of

delegated legislative authority.

PRELIMINARY STATEMENT

By prehearing stipulation, the issues herein were narrowed as governed by

Sections 120.52(8)(c), (d), and (e) F.S. [1992 Supp.].

At commencement of formal hearing, Roberta Agner, the administrator of

Madison County Memorial Hospital, voiced a desire to testify in support of the

rule. She had not been subpoenaed nor called by either party as a witness. By

stipulation of the parties, however, she was called as the Hearing Officer's

witness, and permitted to testify in narrative format outside the hearing of all

other witnesses, subject to objections and cross examination by each party.

Ralph Gray and Linda Enfinger also testified orally. By stipulation, the

deposition of Dr. James Conn, M.D., expert, was admitted in lieu of his oral

testimony as Respondent's exhibit. The parties also submitted a joint composite

exhibit.

A transcript was filed September 8, 1993. Proposed final orders were filed

by each party, respectively, on September 23, 1993. Each proposed finding of

fact has been ruled upon in the appendix to this final order, pursuant to

Section 120.59(2) F.S.

FINDINGS OF FACT

1. Existing Rule 59A-12.006(3)(d) F.A.C. provides:

59A-12.006 Quality of Care. Each HMO or PHC

shall:

(3) Ensure that the health care services it

provides or arranges for are accessible to

the subscriber with reasonable promptness.

Such services shall include, at a minimum:

(d) Average travel time from the HMO

geographic services area boundary to the

nearest primary care delivery site and to the

nearest general hospital under arrangement

with the HMO to provide health care services

of no longer than 30 minutes under normal

circumstances. Average travel time from the

HMO geographic services area boundary to the

nearest provider of specialty physician

services, ancillary services, specialty

inpatient hospital services and all other

health services of no longer than 60 minutes

under normal circumstances. The AHCA shall

waive this requirement if the HMO provides

sufficient justification as to why the

average travel time requirement is not

feasible or necessary in a particular

geographic service area;

2. The existing rule in final form, supra, was adopted in February 1992

following extensive "workshopping" and other public hearing procedures. There

is no suggestion herein that there are any enacting defects with regard to this

rule.

3. Validity of the rule is challenged solely under Sections 120.52(8)(c),

(d), and (e) F.S. [1992 Supp.]. The grounds of invalidity alleged are that:

The rule enlarges, modifies, or contravenes

the specific provisions of the law

implemented, i.e., Section 641.49, Section

641.495(3) and Section 641.56, F.S.;

The rule is vague, fails to establish

adequate standards for agency decisions, or

vests unbridled discretion in the agency; or

The rule is arbitrary and capricious.

4. Petitioner, Healthplan Southeast, Inc., (Healthplan), is a Florida

corporation based in Tallahassee, Florida, and is a health maintenance

organization (HMO) which provides comprehensive health care services to its

subscribers.

5. Petitioner has requested a waiver under the challenged rule. The

agency's denial of that request for a waiver is the subject of DOAH Case No. 93-

2606, and involves disputed issues of material fact.

6. Respondent, Agency for Health Care Administration (AHCA), is the state

agency charged with the responsibility of implementing, interpreting, and

enforcing the rules adopted pursuant to the authority set forth in Section

641.56, F.S.

7. The Department of Health and Rehabilitative Services, (HRS), adopted

Rule 10D-100.006(2)(a), the predecessor to Rule 59A-12.006(3)(d) as an agency

rule in 1988.

8. At the time of adoption of Rule 10D-100 in 1988, Ralph Gray was Unit

Manager of the Managed Care Unit at HRS and was responsible for promulgating and

implementing the rule.

9. At the time Mr. Gray inherited the responsibility of promulgating Rule

10D-100, some preliminary work had already been performed and a draft rule

existed which already included a requirement that the average travel time to the

nearest primary care delivery site or the nearest institutional service site be

thirty minutes or less.

10. Mr. Gray accepted the draft that he inherited and moved forward with

the rule adoption process without doing any independent investigation to

determine the origin or validity of the thirty minute average time requirement.

11. The rule as it was originally adopted in 1988, provided that HMOs

should ensure that health care provided for subscribers was accessible with

reasonable promptness by ensuring that the average travel time from an HMO

geographic service area boundary to the nearest primary care delivery site or to

the nearest institutional service site would be no longer than thirty minutes

under normal circumstances.

12. The specific language of the rule, as it existed from 1988 until

February 1992, simply required an HMO to ensure that a subscriber had access to

either a primary care delivery site or an institutional service site within an

average travel time of thirty minutes. The rule as it was applied by the agency

from 1988 until February 1992 did not require that an HMO provide a subscriber

access to both a primary care delivery site and an institutional service site

within thirty minutes. Neither did the rule as applied from 1988 to 1992

require that the institutional service site be under contract with the HMO.

13. Amendments to Rule 10D-100 were proposed in 1991 in response to

amendments to Chapter 641, Part IV, F.S. enacted by the 1991 Legislature and to

establish additional quality of care standards for HMOs and Prepaid Health

Clinics (PHCs).

14. In 1991-1992, Ralph Gray was again the person in charge of

implementing amendments to Rule 10D-100 that were necessary in order to comply

with the statutory changes in 1991. Mr. Gray assembled a team to assist him in

the rule adoption process. In addition to Mr. Gray, the team consisted of Linda

Enfinger, Registered Nurse Specialist with the agency's HMO Unit and Dr. James

Conn, M.D., Consultant to the Agency Office of Licensure and Certification.

15. The rule amendments at issue herein included a change from "or" to

"and" in the language of the rule which resulted in the thirty minute average

travel time requirement being applicable to both primary care delivery sites and

general hospitals under arrangement with the HMO to provide health care

services. This change was not specifically mandated by the changes to Chapter

641 F.S. adopted by the Legislature in 1991.

16. The change from "or" to "and" came about because of concern informally

expressed to team members about HMO subscribers in northern Dade County and in

Broward County having to travel long distances over considerable periods of time

in congested traffic situations to obtain hospital services, and focused upon

the Miami--Ft. Lauderdale population concentration corridor which is complex in

roadways and traffic patterns and in its number of people and motor vehicles.

17. There were no formal written complaints espousing the foregoing

concept of traffic congestion and excessive distance to HMO provider hospitals

in Dade and Broward counties, and the agency neither conducted nor commissioned

any specific formal review or study to verify the presence or absence of such a

problem either in Dade--Broward or in any other geographic area of the state.

However, Mr. Gray reviewed listings of their providers supplied to the agency by

HMOs and determined for himself that there were accessibility problems in the

Dade--Broward area.

18. No issue or concern clearly in opposition to the thirty minute average

travel time restriction was raised in any workshop or public hearing during the

1991-1992 rule amendment process. Petitioner did not appear at the December 19,

1991 public hearing. Letters from the public in response to that public hearing

did not contain adverse comments regarding the thirty minute travel requirement.

Letters from the public during this process generally supported the time

requirement upon accessibility grounds. A concomitant thrust of the public

comment letters was to the effect that the agency should encourage HMOs to sign-

up licensed local general hospitals in rural areas such as Madison County

because of the need for such services from the HMOs.

19. Opinion testimony offered at formal hearing herein that the thirty

minute average travel time requirement as included in the predecessor rule was

probably originally based on federal regulation 42 CFR 5 was speculative and

unpersuasive. However, it is clear that the time limit, at least, was carried

over from the 1988 HRS rule.

20. No witness knew with certainty that the 1983 version of 42 CFR 5,

dealing with the federal criteria for designating geographic areas having

shortages of primary medical care professionals, was taken into consideration at

the time the state's 1988 HMO rule was drafted. The 1992 version of 42 CFR 5

apparently applies to correctional institution populations who must usually have

care providers travel to them, and became effective in October 1992, eight

months after the new rule amendments were finally promulgated. On the other

hand, the use of the thirty minute average travel time figure in CFR from 1983

to date is indicative of a continuing industry standard.

21. Mr. Gray and Dr. Conn each had the "sense" or "impression" that thirty

minutes average travel time was an industry standard. Mr. Gray's opinion in

this regard was based on an absence of any serious question or challenge to this

provision at any of the public meetings during the 1991-1992 rule amendment

process. Dr. Conn's opinion was partly based on the same factor. However, his

opinion is more persuasive because it is based, in part, upon his personal

experience in the private health industry sector as Medical Director of the

Capital Health Plan HMO from 1981 through 1982.

22. During the amendment process, the agency did not conduct any formal

studies to determine whether the thirty minute average travel time requirement

had any validity or in any way satisfied the statutory mandate to ensure access

to health care services with reasonable promptness. However, at formal hearing,

the consistent and unrefuted expert medical and nursing testimony was to the

effect that excessive travel time can exacerbate bone fracture, shock, and

hemorrhaging. Dr. Conn specifically testified that there are many medical

conditions that need to be evaluated capably within thirty minutes of the onset

of symptoms. Medical physician Conn and nurse administrator Enfinger, as

experts in their fields, recited factual examples from their own professional

experience of emergency room protocols and general hospital "on-call" physician

rosters which require response time ranging from 15 minutes to 45 minutes of

notification of the occurrence of trauma.

23. Dr. Conn testified as an acknowledged expert in managed health care

that the rule's thirty minutes average travel time provision is a good and

adequate interpretation of the statutory mandate of the enabling legislation at

Section 641.495(3) F.S., to ensure that HMOs provide health care services to

their subscribers with reasonable promptness with respect to geographic

location.

24. According to Mr. Gray, the 1991-1992 rule amendment changing the words

"institutional service site" to "general hospital under arrangement with the

HMO" occurred because the term "general hospital" was thought by agency

personnel to be synonymous with "institutional service site" and because

"general hospital" was thought to be less confusing due to generally understood

industry perceptions of the term. There is no evidence in this record to the

contrary.

25. The change of terms within the rule from "institutional service site"

to "general hospital under arrangement with the HMO," did not draw comments or

raise concern during the rule amendment process, and Dr. Conn testified

convincingly at formal hearing that a primary care physician's office would

probably not have the technical equipment or personnel capabilities of treating

severe emergencies, capabilities that would be present at a general hospital.

26. HMO subscribers are in the nature of a captive audience in that they

are not free to select from any provider if they wish to continue to enjoy the

reduced cost benefits of the HMO provider contract.

27. Emergency-type treatment for a subscriber must be paid for by his HMO

even if that treatment was rendered in a health care facility not signed up with

the HMO.

28. Roberta Agner, administrator of Madison County Memorial Hospital,

testified that the rule as amended acts to protect those subscribers receiving

HMO services and the HMO itself by insuring adequate health care through the

HMO. Ms. Agner's foregoing opinion is colored by the fact that without the new

rule in effect, the Petitioner's HMO subscribers in Madison County may come to

Ms. Agner's hospital, which is currently not signed up with Petitioner's HMO,

only for life and death situations if they are to remain assured of payment of

their fees by their HMO.

29. Nonetheless, Ms. Agner's testimony is credible that HMO subscribers

sometimes perceive symptoms such as acute chest pain as an emergency situation

and utilize a local non-HMO facility only to discover after diagnosis and

treatment that the HMO does not acknowledge the situation as a compensable

emergency (life or death situation) because upon medical hindsight, the

precipitating symptom is not, in fact, a heart attack. She gave several similar

medical conditions that routinely result in such disputes. The greater weight

of all the evidence is that prudent patients and hospital emergency rooms must

treat these symptoms initially as emergencies. From this, the undersigned

reasonably infers that the absence of the thirty mile rule could have a life-

threatening "chilling effect" on HMO subscribers promptly seeking truly

necessary emergency health care for fear of making an expensive wrong self-

diagnosis.

30. Without the challenged rule provision, a subscriber to Petitioner's

HMO living in Madison County, Florida could have to travel from as far away as

the Suwannee River (the eastern boundary) to Tallahassee in Leon County to

receive hospital services. Without the rule, such a subscriber would have to

travel sixty minutes average travel time (distance divided by legal speed limit

equals time) from downtown Madison, which is not at the eastern boundary, to

either provider hospital in Tallahassee. This trip's average travel time in

unusual circumstances could be more than sixty minutes. As found supra, many

conditions routinely require medical attention in a general hospital within 15

to 45 minutes. The rule as currently written has demonstrable impact on

subscribers living in rural areas receiving health care services from their HMO

promptly.

31. Petitioner presented no evidence specifically attacking the portion of

the rule providing for the sixty minute average travel time for specialty

physician services, specialty inpatient hospital services, and all other health

services.

32. Petitioner complained that the agency has no uniform interpretation or

guidelines for interpreting the rule's terms, "average travel time" and "normal

circumstances." Despite such assertion, the rule is clear on its face. Each

witness who was asked to apply the rule used standard dictionary definitions and

elementary school mathematical formulas. Each witness uniformly started with

the premise that distance calculated by existing roadways, divided by legal

speed limits, would equal "average travel time" under "normal circumstances."

All witnesses were able to list numerous hypothetical factual situations,

including but not limited to weather and traffic conditions, which might render

a travel time "not normal," but which would have to be weighed and considered on

a case by case basis.

33. The rule provides that the agency shall waive the average travel time

requirement if an HMO provides "sufficient justification" as to why the

requirement is not "feasible" or "necessary" in a particular geographic service

area. Thus, an HMO which cannot meet the average travel time requirement of the

rule still has the opportunity to prove the requirement ought not to apply to

it, bearing the burden to go forward and the burden of proof. This is clearly a

flexible standard designed to accommodate a variety of "not normal"

circumstances.

34. Petitioner's assertion that the rule is invalid because it does not

establish a uniform interpretation or guidelines to supplement or explain

"feasible" or "necessary," is not persuasive since, as used in the rule, these

terms are clearly susceptible of interpretation by dictionary and of being

applied on a case by case factual basis. Some types of evidence which agency

personnel or the HRS consultant, Dr. Conn, advanced as probably going to prove

"sufficient justification" were improved medical techniques, modes of

transportation such as rescue flights, and unavailability of any accredited or

licensed general hospitals in a given geographic service area. In such

situations, the rule's waiver provision provides balance to the rule's initial

thirty minute travel requirement.

CONCLUSIONS OF LAW

35. The Division of Administrative Hearings has jurisdiction over the

parties and subject matter of this cause pursuant to Section 120.56, F.S.

36. Section 641.495(3) F.S. [1991] provides, in pertinent part:

(3) The organization shall ensure that the

health care services it provides to

subscribers, including physician services as

required by s. 641.19(7)(d) and (e), are

accessible to the subscribers, with

reasonable promptness, with respect to

geographic location, hours of operation,

provision of after-hours service, and

staffing patterns within generally accepted

industry norms for meeting the projected

subscriber needs. (Emphasis supplied)

37. The rule in question seeks to interpret, implement, and enforce the

emphasized statutory language.

38. The inclusion of the term, "general hospital under arrangement with

the HMO" in the rule is not an expansion of statutory authority just because

general hospitals are not specifically named in the statute as are physician

services. Indeed, the statute refers first to all "health care services the HMO

provides to subscribers," and in determining whether an agency has enlarged upon

its statutory framework, the court may look at the entire statutory framework.

See, United States Shoe Corp. v. DPR, Bd. of Opticianary, 578 So.2d 376 (Fla.

1st DCA 1991). The inclusion in the rule of the term "general hospital under

arrangement with the HMO," is not an enlargement, modification, or contravention

of the statute. Nor is it capricious or arbitrary.

39. If anything, the rule interprets the statutory term, "reasonable

promptness, with respect to geographic location." It does not enlarge, modify,

or contravene the statute. There is nothing vague about the rule or when it is

to be applied. The rule comes into play when an HMO is certified, renews its

certification, or expands its area of operation. The rule sets a reasonable

standard, subject to a reasonable waiver, the waiver to be determined upon the

facts of each case.

40. A similar travel time of thirty minutes has been promulgated in the

federal sector in connection with health manpower shortage areas. It is also

noted that a similar travel time of thirty minutes has been promulgated in

several HRS accessibility rules for certificates of need. See, for instance,

Rule 59C-1.038(9)(a) F.A.C. Although the evidence falls short of establishing

that federal Rule 42 CFR 5 directly influenced the drafting of the challenged

rule, its predecessor rule, or other similar state health care rules, it is

reasonable to conclude from these rules and all the evidence that thirty minutes

travel time is an industry standard.

41. The challenged rule goes a step further than just establishing a

reasonable average travel time. It provides HMO applicants an opportunity to

show when thirty minutes is altered by "not normal circumstances" and any other

reason a waiver would be "substantially justified." Thus, the average travel

time established by rule does not rigidly control the granting or withholding of

an HMO certificate of authority, renewal of authority, or expansion of

authority/territory. Applicants have the opportunity to demonstrate eligibility

by diverse means on a case by case basis. By analogy, see Humana, Inc. v. Dept.

of Health and Rehabilitative Services, 469 So.2d 889 (Fla. 1st DCA 1985). Cf.

Dept. of Health and Rehabilitative Services v. Johnson and Johnson Home Health

Care, Inc. 947 So.2d 361 (Fla. 1st DCA 1984).

42. Pursuant to Section 641.56 F.S., the agency is authorized to

promulgate rules "not inconsistent with law, which may be necessary to carry out

the duties and authority conferred on the department by this part and to protect

the health, safety, and welfare of the public." In cases such as this, where an

agency is granted broad rulemaking authority by statute, " . . . the validity

of regulations promulgated thereunder will be sustained so long as they are

purposes of the enabling Legislation . . ." See, Florida Beverage Corporation

v. Wynne, 306 So.2d (Fla. 1st DCA 1975).

43. One who attacks the validity of a rule on grounds of arbitrariness or

capriciousness carries the burden of demonstrating by a preponderance of the

evidence that the rule is not supported by fact or logic, was adopted without

thought or reason, or is otherwise not based on competent, substantial evidence.

See, Agrico Chemical Company v. State, Department of Environmental Regulation,

365 So.2d 769 (Fla. 1st DCA 1979); Jax Liquor's, Inc. v. Division of Alcoholic

Beverages and Tobacco, et al., 388 So. 2d 1306 (Fla. 1st DCA 1980); Grove Isle,

Ltd. v. State, Department of Environmental Regulation, 454 So.2d 571 (Fla. 1st

DCA 1984).

44. Agencies are to be accorded wide discretion in the exercise of their

lawful rulemaking authority. See, Florida Commission of Human Relations v. Human

Development Centers, 413 So.2d 1251 (Fla. 1st DCA 1982).

45. Further, the agency's interpretation of a statute need not be the sole

possible interpretation or even the most desirable one, it need only be within

the range of possible interpretations. See, Department of Administration v.

Nelson, 424 So.2d 852 (Fla. 1st DCA 1982); Department of Professional

Regulation, Board of Medical Examiners v. Durrani, 455 So.2d 215 (Fla. 1st DCA

1984); General Telephone Co. of Florida v. Florida Public Service Commission,

446 So.2d 1063 (Fla. 1984).

46. The weight of the evidence is that the rule amendment promulgation

process was reasonable and rational. The thirty minute average travel time

provision perhaps was not as thoroughly investigated and debated as other parts

of the rule during the rule amendment process only because it was not directly

challenged in the course of that process and was not challenged as a "proposed

rule" under Section 120.54 F.S. Also, the thirty minute provision meets an

industry standard and had been included in the rule since 1988. Only the

amendment of other terms has somewhat altered the effect of the original thirty

minute provision. It is enough that at formal hearing pursuant to Section

120.56 F.S., it was clearly demonstrated that the thirty minute requirement of

the current rule as now in effect, made applicable to both "the nearest primary

care delivery site and to the nearest general hospital under arrangement with

the HMO" has a basis in fact and logic.

47. Where an agency has responded to rulemaking incentives and has allowed

affected parties to help shape rules they know will regulate them in the future,

the judiciary must not overly restrict the range of the agency's interpretive

powers. Permissible interpretations of statutes must and will be sustained,

though other interpretations are possible and may even seem preferable according

to some views. See, State Dept. of Health and Rehabilitative Services v. Framat

Realty, Inc., 407 so.2d 238 (Fla. 1st DCA 1981). The test laid down in

Department of Professional Regulation, Board of Medical Examiners v. Durrani,

supra, is not whether the rule under review is the best or even the preferred

interpretation, but that it is a possible interpretation. In view of the

evidence presented at formal hearing, the agency's interpretation of promptness

is reasonable.

48. The challenged rule provision is a possible interpretation and within

the agency's rule making authority pursuant to Section 641.56 F.S. and should be

held valid.

49. Petitioner bears the duty to go forward and the burden of proof

herein. Since no evidence with regard to the sixty minute requirement was

offered, that requirement's invalidity has not been established.

RECOMMENDATION

Upon the foregoing Findings of Fact and Conclusions of Law recited herein,

it is ORDERED that

Existing Rule 59A-12.006(3)(d) F.A.C. constitutes a valid exercise of

delegated legislative authority.

DONE AND ORDERED this 19th day of November, 1993, at Tallahassee, Florida.

___________________________________

ELLA JANE P. DAVIS, Hearing Officer

Division of Administrative Hearings

The De Soto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399-1550

[phone]

Filed with the Clerk of the

Division of Administrative Hearings

this 19th day of November, 1993.

APPENDIX TO FINAL ORDER 93-2721RX

The following constitute specific rulings, pursuant to S120.59(2), F.S.,

upon the parties' respective proposed findings of fact (PFOF).

Petitioner's PFOF:

1-15 Accepted, but material unnecessary, subordinate or

cumulative to the facts as found has not been adopted.

16 Rejected as not supported by the record and as

unpersuasive legal argument

17-21 Accepted in part and rejected in part upon the record

evidence as a whole and as covered in FOF 32-34. What

is rejected is not dispositive or controlling for the

reasons set out in the FOF and COL.

22 Accepted in FOF 20.

Respondent's PFOF:

1-5 Accepted, but material unnecessary, subordinate or

cumulative to the facts as found has not been adopted.

More specifically, the excessive wordiness of the

proposals as to who examined the witness or whether oral

testimony was given upon direct or cross examination or

upon redirect examination has been excluded as

irrelevant.

6-18 These proposals amount to identification of various

exhibits by a witness. The exhibits are in evidence and

were considered. Immaterial matters have not been

adopted. The material substance of those exhibits and

the oral evidence and stipulations concerning them are

covered in FOF 3, 18-21.

19-20 Rejected as stated because misleading as stated.

However, official recognition was taken of 42 CFR 5 in

both its forms. Its significance is covered in FOF 19-

21.

21 Accepted, but material unnecessary, subordinate or

cumulative to the facts as found has not been adopted.

22 Rejected as stated because not comprehensive of all

testimony as stated. Covered in FOF 5, 32, and 34 as

supported by the record as a whole.

23-30 Accepted, but material unnecessary, subordinate or

cumulative to the facts as found has not been adopted.

More specifically, the excessive wordiness of the

proposals as to who examined the witness or whether oral

testimony was given upon direct or cross examination or

upon redirect examination has been excluded as

irrelevant. Additionally, proposals which amounted to

no more than identification of exhibits were excluded as

subordinate. The exhibits themselves together with

relevant testimony have been considered and facts found

accordingly.

31-32 Rejected as stated because misleading as stated.

However, official recognition was taken of 42 CFR 5 in

both its forms. Its significance is covered in FOF 19-

21.

33-35 Accepted, but material unnecessary, subordinate or

cumulative to the facts as found has not been adopted.

More specifically, the excessive wordiness of the

proposals as to who examined the witness or whether oral

testimony was given upon direct or cross examination or

upon redirect examination has been excluded as

irrelevant.

COPIES FURNISHED:

Michael O. Mathis, Esquire

Agency for Health Care Administration

325 John Knox Road, Suite 301

The Atrium Building

Tallahassee, Florida 32303

John C. Pelham, Esquire

Pennington, Haben, Wilkinson, Culpepper,

Dunlap, Dunbar, Richmond, and French, P.A.

Post Office Box 13527

Tallahassee, Florida 32317-3527

Carroll Webb, Executive Director

Administrative Procedures Committee

Holland Building, Room 120

Tallahassee, Florida 32399-1300

Sam Power, Agency Clerk

Agency for Health Care Administration

The Atrium Building, Suite 301

Tallahassee, Florida 32303

NOTICE OF RIGHT TO JUDICIAL REVIEW

PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO JUDICIAL

REVIEW PURSUANT TO SECTION 120.68, FLORIDA STATUTES. REVIEW PROCEEDINGS ARE

GOVERNED BY THE FLORIDA RULES OF APPELLATE PROCEDURE. SUCH PROCEEDINGS ARE

COMMENCED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF THE

DIVISION OF ADMINISTRATIVE HEARINGS AND A SECOND COPY, ACCOMPANIED BY FILING

FEES PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL, FIRST DISTRICT, OR

WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE PARTY

RESIDES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE

ORDER TO BE REVIEWED.