THE AGENCY FOR HEALTH CARE ADMINISTRATION (AHCA)

FAIR HEARING REQUEST

MAIL TO: Agency for Health Care Administration

FAX: 1- 239-338-2641

 

 

2727 Manhan Drive

 

 

Email: MedicaidHearingUnit@ahca.myflorida.com

Tallahasee, FL 32309

 

 

Call: 1-877-254-1055

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

Date of Birth:

 

Phone:

Who is

 

 

 

 

 

 

 

 

Requesting a

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

Hearing?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Authorized

Name:

 

 

Representative Signature:

Representative

 

 

 

 

 

 

 

 

(if any)

 

 

 

 

 

 

 

 

 

Relationship:

 

 

Phone:

 

 

 

 

 

 

 

 

 

 

 

Translator

 

 

YES

 

NO

Language Needed:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insurance

Name:

 

 

Phone:

 

 

 

 

 

 

 

 

 

 

Company:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Denied

Date of Decision to Deny:

Claim/Authorization Number:

 

 

 

 

 

 

 

 

Service:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I

WANT A FAIR HEARING. MY PLANS DECISION IS WRONG BECAUSE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Claimant Signature:

 

 

 

Date: