Adult Cystic Fibrosis Program

How to Apply

(Each of the following five is required as a first time applicant.)

1. Provider Application Instructions (For first time applicants only) (pdf 51.91kb/4 pages)
2. Provider Qualifications (pdf 63.25kb/4 pages)
3. ACF Medicaid Waiver Application (pdf 2.12mb/13 pages)
4. Non-Institutional Provider Agreement Form (55.75kb/3 pages)
5. NPI Registration Application (pdf 546.65kb ) (only use if you have not previously filled out)

Information for Providers Already Enrolled in Another WAIVER

1. Application for a New Location Code (pdf 37.32kb/2 pages)
2. Payment Method Authorization Agreement (pdf 207.78kb/2 pages)
3. All applicable licenses, certifications and other proof of qualifications as required.
4. NPI Registration Application (pdf 546.65kb) (only use if you have not previously filled out)
5. Electronic Data Interchange Agreement (pdf 40.49kb/2 pages)

For additional information on provider enrollment for the ACF Medicaid Waiver please call your local Medicaid Waiver Specialist or this office at the number provided below.

You can follow the status of your application by going to http://portal.flmmis.com/FLpublic/default.aspx and clicking on Provider enrollment for more information.

IMPORTANT ENROLLMENT INFORMATION - PLEASE READ THOROUGHLY

 Medicaid Referral Agreement (pdf 54.79kb/6 pages)
 ACF Rates Schedule  (pdf 15.25kb)
 

• Copies of certification, licenses and credentials for specific service areas are required at the time of application submission. [See Core Services for specifics].
• You may obtain a fingerprint card by contacting your local Medicaid office at http://www.fdhc.state.fl.us/Medicaid/Area, by contacting your local ACF Medicaid Waiver Specialist or by calling the toll free number listed below.
• Refer to the Application Checklist.

For New Providers

Florida Medicaid offers a Web portal which provides communication, data exchange, and self-service tools to the provider community. The portal consists of both public and secure areas. The public area contains general information such as program awareness, notices and forms, and allows users to respond to surveys. The secure area allows access to your personal information and offers the following options:

• View information found on your provider file;
• View contact information;
• View training schedules and locations using the Area Office contact page; and
• Receive training using computer-based training (CBT) courses.
• Request eligibility verifications,
• Request and track prior authorization and referrals.
• Submit and track claims;
• Receive alerts and claims;
• Receive Medicaid policy updates and
• Request changes to your provider file.

Please visit http://portal.flmmis.com/FLPublic/Provider_Home/tabId/36/Default.aspx to learn how you can enroll to obtain access to Medicaid's provider community of information.

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Department of Health
Brain and Spinal Cord Injury Program
4052 Bald Cypress Way, Bin C25
Tallahassee, Florida 32399-1744

Program Toll Free Number
(866) 875-5660
Program Fax Number
(850) 921-0499