Florida Department of State and Division of Library and Information Services
Notice: 18753415
Final Adopted Version in F.A.C.
Department: AGENCY FOR HEALTH CARE ADMINISTRATION
Division: Medicaid
Chapter: GENERAL MEDICAID

VIEW NOTICE

Overview
RULE:
59G-1.045   Medicaid Forms
RULE FILE DATE: 3/16/2017
RULE EFFECTIVE DATE: 4/5/2017
HISTORY NOTES: 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.
OVERSIGHT COMMITTEE: Joint Administrative Procedures Committee
Florida Administrative Law Central Online Network (F.A.L.C.O.N.)
RELATED COURT CASES: Division of Administrative Hearings
FEDERAL RULES
AND REGULATIONS: 		Electronic Code of Federal Regulations
HOW TO LINK TO
THIS NOTICE: 		http://www.flrules.org/gateway/ruleno.asp?id=59G-1.045&Section=0
REFERENCE MATERIALS: Ref-07012 Medical Certification for Medicaid Long-term Care Services and Patient Transfer, AHCA Form 5000-3008
Ref-07013 State of Florida Abortion Certification Form, AHCA MedServ Form 011
Ref-07014 State of Florida Exception to Hysterectomy Acknowledgment Requirement, ETA-5001
Ref-07015 State of Florida Hysterectomy Acknowledgment Form, HAF-5000
Ref-07915 Unborn Activation Form, AHCA Form 5240-006, February 2017
Ref-07926 The United States Department of Health and Human Services’ Consent for Sterilization Form - HHS-687 (10/12) (Consent for Sterilization Form)


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