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 3/2017
AHCA MedServ Form 004 Part A1 Preadmission Screen and Resident Review (PASRR) Resident Review – Evaluation Request Form 3/2017
AHCA-MedServ Form 011 State of Florida Abortion Certification Form 6/2016
AHCA-Med Serv Form 015 Custom Wheelchair Evaluation 1/2007
AHCA-Med Serv Form 019 Early Intervention Services Request To Exceed Medicaid Limitations 8/2007
AHCA-Med Serv Form 022 Agency Certification Children’s Mental Health Targeted Case Management 6/2007
AHCA-Med Serv Form 023 Agency Certification Adult Mental Health Targeted Case Management 6/2007
AHCA-Med Serv Form 024 Agency Certification Intensive Case Management Team Services Adult Mental Health Targeted Case Management 6/2007
AHCA-Med Serv Form 025 Case Management Supervisor Certification Children’s Mental Health Targeted Case Management 7/2006
AHCA-Med Serv Form 026 Case Management Supervisor Certification Adult Mental Health Targeted Case Management 7/2006
AHCA-Med Serv Form 027 Case Manager Certification Children’s Mental Health Targeted Case Management 7/2006
AHCA-Med Serv Form 028 Case Manager Certification Adult Mental Health Targeted Case Management 7/2006
AHCA-Med Serv Form 029 Children’s Certification Children’s Mental Health Targeted Case Management 7/2006
AHCA-Med Serv Form 030 Adult Certification Adult Mental Health Targeted Case Management 7/2006
AHCA-Med Serv Form 031 Adult Certification Intensive Case Management Team Services Adult Mental Health Targeted Case Management 7/2006
AHCA-Med Serv Form 032 Medicaid 30-Day Certification For Children’s Or Adult Mental Health Targeted Case Management 6/2007
AHCA-Med Serv Form 038 Crossover With TPL Claim And/Or Adjustment Form 7/2008
AHCA Form 5000-3008 Medical Certification for Medicaid Long-term Care Services and Patient Transfer [1.32MB PDF] 6/2016
AHCA Form 5000-3008 Medical Certification for Medicaid Long-term Care Services and Patient Transfer Instructions 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 12/2012
AHCA Form 5000-3511 Authorization For Comprehensive Behavioral Health Assessment 3/2014
AHCA Form 5000-3512 Comprehensive Behavioral Health Assessment Agency and Practitioner Self-Certification 3/2014
AHCA Form 5000-3513 Specialized Therapeutic Foster Care Provider Agency Self-Certification 3/2014
AHCA Form 5000-3514 Authorization for Specialized Therapeutic Foster Care 3/2014
AHCA Form 5000-3515 Authorization for Crisis Intervention 3/2014
AHCA Form 5000-3519 Provider Agency Acknowledgement for Therapeutic Group Care 3/2014
AHCA Form 5000-3521 Authorization for Therapeutic Group Care Services 3/2014
AHCA Form 5000-3522 Certification of Eligibility 3/2014
AHCA Form 5000-3523 Provider Agency Self-Certification 3/2014
AHCA Form 5000-3527 Medicare Part C-Medicaid CMS-1500 Crossover Invoice 7/2008
AHCA Form 5000-3528 Medicare Part C-Medicaid UB-04 Crossover Invoice 7/2008
AHCA Form 5240-06 Unborn Activation Form 4/2017
HHS-687 Consent For Sterilization 4/2017
HHS-687-1 Consentimiento Para La Esterilizacion 11/2006
DPA 1041 Prior Authorization For Dental Services 7/2008
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 7/2008
  Florida Medicaid Claims Order Form 7/2008
  Pharmacy Miscellaneous Form  
  Request for Multi-Source Brand Drug  
  Unit-Dose Returns To Stock Reimbursement  
  PAC Case Management Agency Transfer Request  
  PAC Physician Referral and Request for Level of Care Determination – CARES Form 67 8/2001
  PAC Service Authorization Form  
  PAC Waiver Case Management and Comprehensive Needs Assessment Protocol  
  PAC Waiver Enrollment Application  
  PAC Waiver Level of Need Assessment Case Management Tool  
  PAC Waiver Plan of Care Summary  
  PHC Initial Care Management Assessment 6/2002
  Request for Plan of Care Expenditure Exception