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Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form
AHCA 5000-3008 (JUN 2016)

The AHCA 5000–3008 form is used by the Comprehensive Assessment and Review for Long-Term Care Services (CARES) Program to determine medical eligibility for Medicaid Waiver programs. This form must be signed by a licensed physician, physician assistant, or licensed advanced registered nurse practitioner and submitted to the individual requesting the form or to the local CARES office (refer to CARES map to find the appropriate office). If not licensed in Florida, verification of their appropriate medical license must be available.


As of July 11, 2016, the CARES Program shall only accept the revised Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form – AHCA 5000-3008 (JUN 2016), as incorporated into Rule 59G-1.045, Florida Administrative Code.


This form is used by the Comprehensive Assessment and Review for Long-Term Care Services (CARES) Program to determine medical eligibility for Medicaid Waiver programs. The form must be signed by a licensed physician, physician assistant, or licensed advanced registered nurse practitioner and submitted to the individual requesting the form or to the local CARES office (refer to CARES map to find the appropriate office). If not licensed in Florida, verification of their appropriate medical license must be available.


Informed Consent Form

This form provides consent for CARES to perform an assessment evaluating need for long-term care.



Notice of Privacy Practices

This notice applies to the information and records we have about your health, health status, and the health care and service you receive from the Department in your personal file.


Social Security Number Notice

This notice explains why the Department of Elder Affairs is collecting your Social Security number.


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