The purpose of the amendment to Rule 59G-1.045, Florida Administrative Code, is to update certain forms required under the Florida Medicaid Program. The amendment updates existing forms and incorporates by reference additional forms that are ...

 

AGENCY FOR HEALTH CARE ADMINISTRATION

Medicaid

RULE NO.:RULE TITLE:

59G-1.045Medicaid Forms

PURPOSE AND EFFECT: The purpose of the amendment to Rule 59G-1.045, Florida Administrative Code, is to update certain forms required under the Florida Medicaid Program. The amendment updates existing forms and incorporates by reference additional forms that are specified in various Florida Medicaid policies.

SUBJECT AREA TO BE ADDRESSED: Medicaid Forms.

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: October 13, 2016, 10:30 a.m. to 11:30 a.m.

PLACE: In Person: Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Tallahassee, Florida 32308-5407. Remote Listeners: Register to view the presentation at https://attendee.gotowebinar.com/register/3227861951896354820 . A call in number will be provided upon successful registration through which remote attendees may listen to the discussion via telephone.

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: Mary McCullough 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: Mary McCullough, Bureau of Medicaid Policy, 2727 Mahan Drive, Mail Stop 20, Tallahassee, Florida 32308-5407, telephone: [phone], e-mail: [e-mail].

 

THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT IS:

 

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 website at http://ahca.myflorida.com/Medicaid/review/index.shtml.

(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.

(2) 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) 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.

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

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

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

(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-07025.

(6)(7) Unborn Activation Form, AHCA Form 5240-006, June 2016, http://www.flrules.org/Gateway/reference.asp?No=Ref-07016.

Rulemaking Authority 409.919 FS. Law Implemented 409.902, 409.905, 409.912 FS. History–New 9-28-15, Amended 7-11-16,_____.