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Florida dh medicaid family waiver application form 2026
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How to use or fill out Florida DH Medicaid Family Waiver Application Form
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering your personal information in the designated fields, including your name, residence, and mailing address if different. Ensure accuracy as this is crucial for communication regarding your application.
- Answer the questions regarding past medical services and your desire for family planning services. Be honest and thorough to avoid delays in processing.
- List all individuals living in your home, starting with yourself. Include details such as relationship to you, date of birth, and whether they are claimed as tax dependents.
- Provide income information for everyone in your household who receives money. This includes sources of income and how often they are paid. Attach any necessary proof of income.
- Complete the health insurance section by indicating whether you have insurance and if it covers family planning services.
- Read through the Certification and Authorization section carefully before signing and dating the form to confirm that all information is accurate.
- Finally, submit your completed application by mailing or bringing it to your local county health department; do not send it to Medicaid directly.
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medicaid waiver form pdf
Mail or bring this application and any letter you received to your local county health department (see attached list). DO NOT SEND THIS APPLICATION TO MEDICAID.
This program is referred to as a Statewide Medicaid Managed Care (SMMC) and includes two programs: one for Managed. Medical Assistance (MMA) and one for Long-
Children and Families (including the Family Safety and preservation program Financial eligibility is determined through the Florida KidCare application or