Adopted Rules

Florida Medicaid Forms

Form Number	Form Name	Effective Date
AHCA MedServ Form 004 Part A	Preadmission Screen and Resident Review (PASRR) Level I Form [ 322.1 kB ]	3/2017
AHCA MedServ Form 004 Part A1	Preadmission Screen and Resident Review (PASRR) Resident Review – Evaluation Request Form [ 175.3 kB ]	3/2017
AHCA-MedServ Form 011	State of Florida Abortion Certification Form [ ]	6/2016
AHCA-Med Serv Form 015	Custom Wheelchair Evaluation [ 523.5 kB ]	1/2007
AHCA-Med Serv Form 019	Early Intervention Services Request To Exceed Medicaid Limitations [ 96.1 kB ]	8/2007
AHCA-Med Serv Form 022	Agency Certification Children’s Mental Health Targeted Case Management [ 24.1 kB ]	6/2007
AHCA-Med Serv Form 023	Agency Certification Adult Mental Health Targeted Case Management [ 23.9 kB ]	6/2007
AHCA-Med Serv Form 024	Agency Certification Intensive Case Management Team Services Adult Mental Health Targeted Case Management [ 22.4 kB ]	6/2007
AHCA-Med Serv Form 025	Case Management Supervisor Certification Children’s Mental Health Targeted Case Management [ 48.1 kB ]	7/2006
AHCA-Med Serv Form 026	Case Management Supervisor Certification Adult Mental Health Targeted Case Management [ 47.6 kB ]	7/2006
AHCA-Med Serv Form 027	Case Manager Certification Children’s Mental Health Targeted Case Management [ 49.8 kB ]	7/2006
AHCA-Med Serv Form 028	Case Manager Certification Adult Mental Health Targeted Case Management [ 48.9 kB ]	7/2006
AHCA-Med Serv Form 029	Children’s Certification Children’s Mental Health Targeted Case Management [ 69 kB ]	7/2006
AHCA-Med Serv Form 030	Adult Certification Adult Mental Health Targeted Case Management [ 70.6 kB ]	7/2006
AHCA-Med Serv Form 031	Adult Certification Intensive Case Management Team Services Adult Mental Health Targeted Case Management [ 84 kB ]	7/2006
AHCA-Med Serv Form 032	Medicaid 30-Day Certification For Children’s Or Adult Mental Health Targeted Case Management [ 82.2 kB ]	6/2007
AHCA Form 5000-0025	Model Waiver Physician Referral for Individuals at Risk of Hospitalization [ 96.6 kB ]	1/2018
AHCA Form 5000-0123	Agency for Health Care Administration Consent for Voluntary Suspension of Authorized Services for Florida Medicaid State Plan Recipients [ 82 kB ]	8/2017
AHCA Form 5000-0607	Acquired Immune Deficiency Syndrome (AIDS) Physician Referral for Individuals at Risk of Hospitalization [ 134.1 kB ]	1/2018
AHCA Form 5000-0608	Adults with Cystic Fibrosis Physician Referral for Individuals at Risk for Hospitalization [ 82.9 kB ]	1/2018
AHCA Form 5000-3008	Medical Certification for Medicaid Long-term Care Services and Patient Transfer [ 1.3 MB ]	6/2016
AHCA Form 5000-3008	Medical Certification for Medicaid Long-term Care Services and Patient Transfer Instructions [ 38 kB ]	6/2016
AHCA Form 5000-3009	Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) Utilization Review (UR) Plan[ ]	7/2016
AHCA Form 5000-3510	Temporary Service Authorization [ 10.4 kB ]	12/2012
AHCA Form 5000-3511	Authorization For Comprehensive Behavioral Health Assessment [ 15.3 kB ]	3/2014
AHCA Form 5000-3512	Comprehensive Behavioral Health Assessment Agency and Practitioner Self-Certification [ 12.9 kB ]	3/2014
AHCA Form 5000-3513	Specialized Therapeutic Foster Care Provider Agency Self-Certification [ 10.4 kB ]	3/2014
AHCA Form 5000-3514	Authorization for Specialized Therapeutic Foster Care [ 13.8 kB ]	3/2014
AHCA Form 5000-3515	Authorization for Crisis Intervention [ 12.3 kB ]	3/2014
AHCA Form 5000-3519	Provider Agency Acknowledgement for Therapeutic Group Care [ 14.4 kB ]	3/2014
AHCA Form 5000-3521	Authorization for Therapeutic Group Care Services [ 10.8 kB ]	3/2014
AHCA Form 5000-3522	Certification of Eligibility [ 20.6 kB ]	3/2014
AHCA Form 5000-3523	Provider Agency Self-Certification [ 19.4 kB ]	3/2014
AHCA Form 5000-3527	Medicare Part C-Medicaid CMS-1500 Crossover Invoice [ 973.8 kB ]	7/2008
AHCA Form 5000-3528	Medicare Part C-Medicaid UB-04 Crossover Invoice [ 510.9 kB ]	7/2008
AHCA Form 5240-06	Unborn Activation Form [ 85.7 kB ]	4/2017
HHS-687	Consent For Sterilization [ 214.5 kB ]	4/2017
HHS-687-1	Consentimiento Para La Esterilizacion [ 128.6 kB ]	11/2006
ETA-5001	State of Florida Exception to Hysterectomy Acknowledgment Requirement[ ]	6/2016
HAF-5000	State of Florida Hysterectomy Acknowledgment Form [ ]	6/2016
	Provider Inquiry Form [ 121.1 kB ]	7/2008
	Pharmacy Miscellaneous Form [ 1 MB ]
	Request for Multi-Source Brand Drug [ 1 MB ]
	PAC Case Management Agency Transfer Request [ 23.7 kB ]
	PAC Physician Referral and Request for Level of Care Determination – CARES Form 67 [ 54.4 kB ]	8/2001
	PAC Service Authorization Form [ 72.8 kB ]
	PAC Waiver Case Management and Comprehensive Needs Assessment Protocol [ 150.6 kB ]
	PAC Waiver Enrollment Application [ 150.5 kB ]
	PAC Waiver Level of Need Assessment Case Management Tool [ 123.3 kB ]
	PAC Waiver Plan of Care Summary [ 49.8 kB ]
	PHC Initial Care Management Assessment [ 684 kB ]	6/2002
	Request for Plan of Care Expenditure Exception [ 79.2 kB ]

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Adopted Rules

Adopted Rules

Florida Medicaid Forms