AGENCY FOR HEALTH CARE ADMINISTRATION
RULE NO.:RULE TITLE:
59G-1.045Medicaid Forms
NOTICE OF CHANGE
Notice is hereby given that the following changes have been made to the proposed rule in accordance with subparagraph 120.54(3)(d)1., F.S., published in Vol. 42 No. 78, April 21, 2016 issue of the Florida Administrative Register.
The forms in paragraphs (b) and (c) currently exist in the present rule text and were erroneously omitted from the proposed rule text.
(1) 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)(a) Medical Certification for Medicaid Long-term Care Services and Patient Transfer, AHCA Form 5000-3008,_June 2016, http://www.flrules.org/Gateway/reference.asp?No=Ref-____.
(2)(b) Pre-Admission Screen and Resident Review (PASRR) Level I Screen for Serious Mental Illness (SMI) and/or Intellectual Disability or Related Conditions (ID), AHCA MedServ Form 004 Part A, October 2015, http://www.flrules.org/Gateway/reference.asp?No=Ref-05827.
(3)(c) Pre-Admission Screening and Resident Review (PASRR) Resident Review (RR) – Evaluation Request for a Significant Change for Serious Mental Illness (SMI) and/or Intellectual Disability or Related Conditions (ID), AHCA MedServ Form 004 Part A1, October 2015, http://www.flrules.org/Gateway/reference.asp?No=Ref-05828.
(4)(2) State of Florida Abortion Certification Form, AHCA MedServ Form 011, June 2016, http://www.flrules.org/Gateway/reference.asp?No=Ref-____.
(5)(3) State of Florida Exception to Hysterectomy Acknowledgment Requirement, ETA-5001, June 2016,
http://www.flrules.org/Gateway/reference.asp?No=Ref-____.
(6)(4) State of Florida Hysterectomy Acknowledgment Form, HAF-5000, June 2016, http://www.flrules.org/Gateway/reference.asp?No=Ref-____.
(7)(5) Unborn Activation Form, AHCA Form 5240-006, June 2016, http://www.flrules.org/Gateway/reference.asp?No=Ref-____.
