65A-1.400. Forms for Client Notice and Contact

The following forms are used for Public Assistance Programs to provide applicants and recipients with required notice of the agency’s and client’s rights and responsibilities and other necessary program information. These forms are hereby incorporated by reference.

(1) Forms that apply to two or more public assistance programs are:

(a) CF-ES Form 1007, Oct 05, Office of Appeal Hearings Hearing Request

(b) CF-ES Form 2064, Mar 12, Your Rights and Responsibilities

(c) CF-ES Form 2304, Sep 02, Public Assistance Consent to Release Information

(d) CF-ES Form 2305, Oct 05, Relative Caregiver Program Request for Eligibility Consideration

(e) CF-ES Form 2332, Mar 05, Appointment Notice for Face-to-Face Interview

(f) CF-ES Form 2333, Mar 05, Eligibility Redetermination Letter

(g) CF-ES Form 2334, Mar 05, Request for Information

(h) CF-ES Form 2335, Mar 05, Request for Information for Elderly and Disabled Individuals

(i) CF-ES Form 2336, Nov 06, Interim Contact Letter

(j) CF-ES Form 2640, May 05, Temporary Cash Assistance (TCA)/Medicaid/Food Stamp Program Child Support Cooperation Notice

(k) CF-ES Form 2641, May 05, Claim Notice – Good Cause for Refusal to Cooperate

(l) CF-ES Form 2672, Oct 05, Real Property Agreement

(m) CF-ES Form 3052A, Feb 09, Change Report Form

(n) CF-ES Form 3103, Sep 02, Authorized Benefit Representative for Electronic Benefit Transfer

(2) The Food Stamp Program only forms are:

(a) CF-ES Form 2095, May 05, Food Stamp Work Registration Notice

(b) CF-ES Form 2331, Jan 05, Food Stamp Application for SSI Applicants

(c) CF-ES Form 3010, Feb 09, Authorized Representative Designation

(3) The Medicaid only forms are:

(a) CF-ES Form 990, Sep 02, Designation of Beneficiary

(b) CF-ES Form 1056, Feb 03, KidCare Program Notice of Case Action

(c) CF-ES Form 2039, Apr 03, Medical Assistance Referral

(d) CF-ES Form 2040, Feb 03, Informed Consent Form

(e) CF-ES Form 2059, Sep 02, Consent of Disclosure Statement

(f) CF-ES Form 2099, Jul 02, Medicaid Application for Breast and Cervical Cancer Treatment

(g) CF-ES Form 2277, Oct 05, KidCare Program Medicaid Eligibility Review

(h) CF-ES Form 2293, May 10, Child in Care Medicaid Application

(i) CF-ES Form 2514, Jul 03, Authorization to Release Medical Information

(j) CF-ES Form 2613, Oct 05, Financial Information Release

(k) CF-ES Form 2635, Sep 02, Protective Payee Agreement

(l) CF-ES Form 2700, May 10, Health Insurance Application for Pregnant Women

(m) CF-ES Form 2701, Feb 03, Request for Length of Treatment Information

(n) CF-ES Form 2930, Apr 07, Screening for Expedited Medicaid Appointment

(4) The Overpayment and Benefit Recovery only forms are:

(a) CF-ES Form 3400, Feb 2018, Request for Additional Information

(b) CF-ES Form 3410, Feb 2018, Waiver of Administrative Disqualification Hearing With a Program Loss

(c) CF-ES Form 3410A, Feb 2018, Waiver of Administrative Disqualification Hearing Without a Program Loss

(d) CF-ES Form 3414, Nov 07, Disqualification Consent Agreement

(e) CF-ES Form 2338, Feb 2018, Contact Notice

(f) CF-ES Form 2339, Feb 2018, Request for Verification

(g) CF-ES Form 2340, Feb 2018, Home Visit Confirmation Notice

(5) The Temporary Cash Assistance only forms are:

(a) CF-ES Form 2082, Sep 05, Hardship Extension/Exemption Review

(b) CF-ES Form 2094, Jun 09, Statement of the Need for Care

(c) CF-ES Form 2097, Oct 05, Communication and Work Activity Referral

(d) CF-ES Form 2299, Feb 03, Alcohol, Drug Abuse and Mental Health (ADM) Treatment Verification

(e) CF-ES Form 2601, Feb 03, Temporary Cash Assistance Program Refugee Assistance Program

(f) CF-ES Form 4192, May 05, Notice of Work Penalty

The edition date on some forms is listed with a notation that the edition replaces a previous edition that may still be used. This notation is to indicate that the new edition of the form does not implement a policy change and that supplies of the previous edition of a specific form may be exhausted prior to the use of the new edition.

(6) Copies of materials incorporated by reference are available from the ACCESS Florida Headquarter’s Office, 1317 Winewood Boulevard, Tallahassee, Florida 32399-0700, or on the Department’s website at http://www.dcf.state.fl.us/DCFForms/Search/ DCFFormSearch.aspx. Forms CF-ES 3410, CF-ES 3410A, CF-ES 2338, CF-ES 2339, and CF-ES 2340 can also be found at http://www.flrules.org/Gateway/reference.asp?No=Ref-09355; http://www.flrules.org/Gateway/reference.asp?No=Ref-09356; http://www.flrules.org/Gateway/reference.asp?No=Ref-09357; http://www.flrules.org/Gateway/reference.asp?No=Ref-09358; and http://www.flrules.org/Gateway/reference.asp?No=Ref-09359, respectively.

Rulemaking Authority 409.919, 410.033, 414.45 FS. Law Implemented 409.903, 409.904, 410.033, 414.065, 414.075, 414.085, 414.095, 414.105, 414.115, 414.122, 414.31 FS. History–New 4-9-92, Amended 7-1-93, 8-3-94, Formerly 10C-1.400, Amended 12-29-98, 3-18-03, 7-25-06, 1-8-12, 6-4-18.