1. (1) This rule applies to all individuals, groups, and entities that are seeking to enroll, renew, or maintain enrollment as an authorized provider for the Florida Medicaid program.
2. (2) All providers must be in compliance with the provisions of the Florida Medicaid Provider Enrollment Policy, February 2026, incorporated by reference. The policy is available on the Agency for Health Care Administration’s website at http://ahca.myflorida.com/Medicaid/review/index.shtml, and at HYPERLINK "http://www.flrules.org/Gateway/reference.asp?No=Ref-19181"http://www.flrules.org/Gateway/reference.asp?No=Ref-19181.

3. (3) The following forms are incorporated by reference and available on the Florida Medicaid web portal at http://portal.flmmis.com/flpublic, and as follows:

   1. (a) Agency Certification Adult Mental Health Targeted Case Management, AHCA MedServ Form 023, (APR 2024), HYPERLINK "http://www.flrules.org/Gateway/reference.asp?No=Ref-18560"http://www.flrules.org/Gateway/reference.asp?No=Ref-18560.
   2. (b) Agency Certification Children’s Mental Health Targeted Case Management, AHCA MedServ Form 022, (APR 2024), HYPERLINK "http://www.flrules.org/Gateway/reference.asp?No=Ref-18561"http://www.flrules.org/Gateway/reference.asp?No=Ref-18561.
   3. (c) Agency Certification Intensive Case Management Team Services Adult Mental Health Targeted Case Management, AHCA MedServ Form 024, (APR 2024), HYPERLINK "http://www.flrules.org/Gateway/reference.asp?No=Ref-18562"http://www.flrules.org/Gateway/reference.asp?No=Ref-18562.
   4. (d) Comprehensive Behavioral Health Assessment Agency and Practitioner Self-Certification, AHCA Form 5000-3512, May 2014, HYPERLINK "http://www.flrules.org/Gateway/reference.asp?No=Ref-11334" http://www.flrules.org/Gateway/reference.asp?No=Ref-11334.
   5. (e) County Health Department Agreement Provider Credentialing of Behavioral Health Providers and Social Workers, AHCA Form 5000-1066, June 2019, HYPERLINK "http://www.flrules.org/Gateway/reference.asp?No=Ref-11336" http://www.flrules.org/Gateway/reference.asp?No=Ref-11336.
   6. (f) Electronic Data Interchange Agreement, AHCA Form 5000-1062, June 2019, HYPERLINK "http://www.flrules.org/Gateway/reference.asp?No=Ref-11350" http://www.flrules.org/Gateway/reference.asp?No=Ref-11350.
   7. (g) Florida Medicaid Provider Enrollment Application Out-of-State Fee for Service, AHCA Form 5000-1260, (JAN 2021), HYPERLINK "http://www.flrules.org/Gateway/reference.asp?No=Ref-13975" http://www.flrules.org/Gateway/reference.asp?No=Ref-13975.
   8. (h) Florida Medicaid Provider Enrollment Change of Ownership (CHOW) Disclosure Form-Hospital, Institutional Care (ICF) and Skilled Nursing Facility ONLY, AHCA Form 5000-1264, (JAN 2021), HYPERLINK "http://www.flrules.org/Gateway/reference.asp?No=Ref-13976" http://www.flrules.org/Gateway/reference.asp?No=Ref-13976.
   9. (i) Group Membership Authorization, AHCA Form 5000-1061, June 2019, HYPERLINK "http://www.flrules.org/Gateway/reference.asp?No=Ref-13977" http://www.flrules.org/Gateway/reference.asp?No=Ref-13977.
   10. (j) Non-profit Organization Certification – Fingerprinting Exemption, AHCA Form 5000-1261, (JAN 2021), HYPERLINK "http://www.flrules.org/Gateway/reference.asp?No=Ref-13978" http://www.flrules.org/Gateway/reference.asp?No=Ref-13978.
   11. (k) Physician Group Certificate of Ownership, AHCA Form 5000-1068, June 2019, HYPERLINK "http://www.flrules.org/Gateway/reference.asp?No=Ref-11338" http://www.flrules.org/Gateway/reference.asp?No=Ref-11338.
   12. (l) Practitioner Collaborative Agreement, AHCA Form 5000-1067, June 2019, HYPERLINK "http://www.flrules.org/Gateway/reference.asp?No=Ref-11339" http://www.flrules.org/Gateway/reference.asp?No=Ref-11339.
   13. (m) School District Assurance Agreement Provider Credentialing of Behavior Analysts, AHCA Form 5000-1162, June 2019, HYPERLINK "http://www.flrules.org/Gateway/reference.asp?No=Ref-11341" http://www.flrules.org/Gateway/reference.asp?No=Ref-11341.
   14. (n) School District Assurance Agreement Provider Credentialing of Behavioral Sciences Staff, AHCA Form 5000-1160, June 2019, HYPERLINK "http://www.flrules.org/Gateway/reference.asp?No=Ref-11342" http://www.flrules.org/Gateway/reference.asp?No=Ref-11342.
   15. (o) School District Assurance Agreement Provider Credentialing of Mental Health Counselors and Family Therapists, AHCA Form 5000-1161, June 2019, HYPERLINK "http://www.flrules.org/Gateway/reference.asp?No=Ref-11343" http://www.flrules.org/Gateway/reference.asp?No=Ref-11343.
   16. (p) School District Assurance Agreement Provider Credentialing of Psychologists, Behavior Analysts, and Social Workers, AHCA Form 5000-1163, June 2019, HYPERLINK "http://www.flrules.org/Gateway/reference.asp?No=Ref-11344" http://www.flrules.org/Gateway/reference.asp?No=Ref-11344.
   17. (q) School District Assurance Agreement Provider Credentialing of Registered Nurses and Licensed Practical Nurses, AHCA Form 5000-1164, June 2019, HYPERLINK "http://www.flrules.org/Gateway/reference.asp?No=Ref-11345" http://www.flrules.org/Gateway/reference.asp?No=Ref-11345.
   18. (r) School District Assurance Agreement Provider Credentialing of School Health Aides, AHCA Form 5000-1165, June 2019, HYPERLINK "http://www.flrules.org/Gateway/reference.asp?No=Ref-11346" http://www.flrules.org/Gateway/reference.asp?No=Ref-11346.
   19. (s) School District Assurance Agreement Provider Credentialing of Therapists and Therapy Assistants, AHCA Form 5000-1166, June 2019, HYPERLINK "http://www.flrules.org/Gateway/reference.asp?No=Ref-11347" http://www.flrules.org/Gateway/reference.asp?No=Ref-11347.
   20. (t) Special Exempt Entity Certification – Fingerprinting Exemption, AHCA Form 5000-1262, (JAN 2021), HYPERLINK "http://www.flrules.org/Gateway/reference.asp?No=Ref-13979" http://www.flrules.org/Gateway/reference.asp?No=Ref-13979.
   21. (u) State of Florida Agency for Health Care Administration Florida Medicaid Provider Surety Bond, AHCA Form 5000-1064, June 2019, HYPERLINK "http://www.flrules.org/Gateway/reference.asp?No=Ref-11348" http://www.flrules.org/Gateway/reference.asp?No=Ref-11348.
   22. (v) Therapeutic Foster Care Provider Agency Self-Certification, AHCA Form 5000-3513, March 2014, HYPERLINK "http://www.flrules.org/Gateway/reference.asp?No=Ref-11349" http://www.flrules.org/Gateway/reference.asp?No=Ref-11349.

Rulemaking Authority 409.919, 409.961 FS. Law Implemented 409.907, 409.973 FS. History–New 12-25-19, Amended 2-9-22, 4-30-25, 4-8-26.