The purpose of the amendment to Rule 59G-1.045, Florida Administrative Code (F.A.C.), is to include new Florida Medicaid forms in the Rule. The amendment incorporates by reference the Consent for Voluntary Suspension of Authorized Services for ...
AGENCY FOR HEALTH CARE ADMINISTRATION
RULE NO.:RULE TITLE:
59G-1.045Medicaid Forms
PURPOSE AND EFFECT: The purpose of the amendment to Rule 59G-1.045, Florida Administrative Code (F.A.C.), is to include new Florida Medicaid forms in the Rule. The amendment incorporates by reference the Consent for Voluntary Suspension of Authorized Services for Florida Medicaid State Plan Recipients, AHCA Form 5000-0123, August 2017; the Acquired Immune Deficiency Syndrome (AIDS) Physician Referral and Request for Level of Care Determination, AHCA Form 5000-0607,______; and, the Adults with Cystic Fibrosis Physician Referral and Request for Level of Care Determination, AHCA Form 5000-0608,_____.
SUBJECT AREA TO BE ADDRESSED: Medicaid Forms. An additional area to be addressed during the workshop will be the potential regulatory impact Rule 59G-1.045, F.A.C., will have as provided for under sections 120.54 and 120.541, Florida Statutes.
RULEMAKING AUTHORITY: 409.919 FS.
LAW IMPLEMENTED: 409.902, 409.905, 409.912 FS.
A RULE DEVELOPMENT WORKSHOP WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:
DATE AND TIME: November 8, 2017, 2:30 p.m. to 3:00 p.m.
PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Tallahassee, Florida 32308-5407.
Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 48 hours before the workshop/meeting by contacting: Tiffany Glaze. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE DEVELOPMENT AND A COPY OF THE PRELIMINARY DRAFT, IF AVAILABLE, IS: Tiffany Glaze, Bureau of Medicaid Policy, 2727 Mahan Drive, Mail Stop 20, Tallahassee, Florida 32308-5407, telephone: (850)412-4218, e-mail: Tiffany.Glaze@ahca.myflorida.com.
Please note that a preliminary draft of the reference material, if available, will be posted prior to the workshop at http://ahca.myflorida.com/Medicaid/review/index.shtml. Official comments to be entered into the rule record will be received until 5:00 p.m., November 9, 2017 and may be e-mailed to MedicaidRuleComments@ahca.myflorida.com. For general inquiries and questions about the rule, please contact the person specified above.
THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT IS:
59G-1.045Medicaid 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 Wweb site at http://ahca.myflorida.com/Medicaid/review/index.shtml.
(1) Acquired Immune Deficiency Syndrome (AIDS) Physician Referral and Request for Level of Care Determination, AHCA Form 5000-0607,_________, http://www.flrules.org/Gateway/reference.asp?No=Ref-_______.
(2) Adults with Cystic Fibrosis Physician Referral and Request for Level of Care Determination, AHCA Form 5000-0608,_________, http://www.flrules.org/Gateway/reference.asp?No=Ref-_______.
(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-_______.
(4)(1) 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)(2) State of Florida Abortion Certification Form, AHCA MedServ Form 011, June 2016, http://www.flrules.org/Gateway/reference.asp?No=Ref-07013.
(6)(3) State of Florida Exception to Hysterectomy Acknowledgment Requirement, ETA-5001, June 2016, http://www.flrules.org/Gateway/reference.asp?No=Ref-07014.
(7)(4) State of Florida Hysterectomy Acknowledgment Form, HAF-5000, June 2016, http://www.flrules.org/Gateway/reference.asp?No=Ref-07015.
(8)(5) 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-07026.
(9)(6) Unborn Activation Form, AHCA Form 5240-006, (February 2017), http://www.flrules.org/Gateway/reference.asp?No=Ref-07915.
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,_____.
Document Information
- Subject:
- Medicaid Forms. An additional area to be addressed during the workshop will be the potential regulatory impact Rule 59G-1.045, F.A.C., will have as provided for under sections 120.54 and 120.541, Florida Statutes.
- Purpose:
- The purpose of the amendment to Rule 59G-1.045, Florida Administrative Code (F.A.C.), is to include new Florida Medicaid forms in the Rule. The amendment incorporates by reference the Consent for Voluntary Suspension of Authorized Services for Florida Medicaid State Plan Recipients, AHCA Form 5000-0123, August 2017; the Acquired Immune Deficiency Syndrome (AIDS) Physician Referral and Request for Level of Care Determination, AHCA Form 5000-0607,______; and, the Adults with Cystic Fibrosis ...
- Rulemaking Authority:
- 409.919 FS.
- Law:
- 409.902, 409.905, 409.912 FS.
- Contact:
- Tiffany Glaze, Bureau of Medicaid Policy, 2727 Mahan Drive, Mail Stop 20, Tallahassee, Florida 32308-5407, telephone: 850-412-4218, e-mail: Tiffany.Glaze@ahca.myflorida.com. Please note that a preliminary draft of the reference material, if available, will be posted prior to the workshop at http://ahca.myflorida.com/Medicaid/review/index.shtml. Official comments to be entered into the rule record will be received until 5:00 p.m., November 9, 2017 and may be e-mailed to MedicaidRuleComments@...
- Related Rules: (1)
- 59G-1.045. Medicaid Forms