CARES Notices and Forms

The AHCA 5000–3008 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. This form must be signed by a licensed physician, physician assistant, or advanced practice registered nurse. If not licensed in Florida, verification of their appropriate medical license must be provided.

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

Informed Consent Form

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

• Informed Consent – English
• Informed Consent – Spanish
• Informed Consent – Creole

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.

• Department of Elder Affairs Notice of Privacy Practices – English
• Department of Elder Affairs Notice of Privacy Practices – Spanish
• For more information on the Department of Elder Affairs’ HIPAA (Health Insurance Portability and Accountability Act) Privacy Policies and Procedures

Social Security Number Notice

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

• Department of Elder Affairs Social Security Number Notice – English
• Department of Elder Affairs Social Security Number Notice – Spanish