THE AGENCY FOR HEALTH CARE ADMINISTRATION (AHCA)
FAIR HEARING REQUEST
MAIL TO: Agency for Health Care Administration |
FAX: 1- |
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2727 Manhan Drive |
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Tallahasee, FL 32309 |
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Call: |
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Name: |
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Date of Birth: |
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Who is |
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Requesting a |
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Address: |
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Hearing? |
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Authorized |
Name: |
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Representative Signature: |
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Representative |
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(if any) |
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Relationship: |
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Phone: |
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Translator |
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YES |
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NO |
Language Needed: |
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Insurance |
Name: |
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Phone: |
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Company: |
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Denied |
Date of Decision to Deny: |
Claim/Authorization Number: |
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Service: |
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I |
WANT A FAIR HEARING. MY PLANS DECISION IS WRONG BECAUSE: |
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Claimant Signature: |
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Date: |