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This form must be signed by a licensed physician, physician assistant, or advanced practice registered nurse The form entitled “Medical Certification for Medicaid Long-Term Care Services and Patient Transfer” (AHCA) can be found on the Internet at: _for_Long_Term_Care__pdf This form is being submitted to CARES to request a Level of Care for the specified individual below who is applying for the Florida Medicaid Institutional Care Program (ICP) through the Florida Department of Children and Families (DCF) The form entitled “Medical Certification for Nursing Facility/Home and Community-Based Services” (form number AHCA MedServ) has been superseded AHCA Form, _____, incorporated by reference in RuleG, F.A.C. The form entitled “Medical Certification for Medicaid Long-Term Care Services and Patient Transfer” (AHCA) can be found on the Internet at This form is being submitted to CARES to request a Level of Care for the specified individual below who is applying for the Florida Medicaid Institutional Care Program AHCA Form Medical Certification for Medicaid Long-term Care Services and Patient Transfer [ MB ] 6/ AHCA Form Medical Certification for The CO2 emissions of the vehicle depend on the version chosen as well as the options present on the vehicle. If patient seeks eligibility for the Medicaid Institutional Care Program (ICP) or a Medicaid Home and Community-Based Services (HCBS) Waiver The AHCA – form is used by the Comprehensive Assessment and Review for Long-Term Care Services (CARES) Program to help determine medical eligibility for Medicaid Waiver programs. (1) The CO2 emissions given are mixed and expressed in grams STATE OF FLORIDA. G-tube Eating: DialysisFrequency: * S. PHYSICAL FUNCTION Ambulation: * Transfer: Devices: Weight-bearing: Self Rehab Potential (check one) Good Fair Poor Assistance Difficulty Swallowing J-tube TPN Other Supplements: PEG Insertion The AHCA form must be filled out in a complete and accurate manner. *Sections required for Medicaid.