My Recipients

	“Please send the authorization document through any of the following method.Please ensure that the 
	document includes the recipient’s name, and recipient number,or gold card number, or SSN.”
		Email: flenrollmentrequest@automatedhealth.com 
		Fax: (850) 402 – 4678 
		Mail: Agency for Health Care Administration
		 P.O. Box 5197 Tallahassee,
		 FL 32314

Would you like to fill out a Designated Authorization Representative (DAR) Form or submit a DAR form or Authorization document?

Yes No

Fill out a New DAR Form
Submit a DAR Form or Authorization document

	“Please send the authorization document through any of the following method.Please ensure that the 
	document includes the recipient’s name, and recipient number,or gold card number, or SSN.”
		Email: flenrollmentrequest@automatedhealth.com 
		Fax: (850) 402 – 4678 
		Mail: Agency for Health Care Administration
		 P.O. Box 5197 Tallahassee,
		 FL 32314

Next

* Address
* City
* State
* Zip Code
* Government Issued ID: Select Option Driver’s License State ID Passport Green Card Other

* States: Select State

* Country: Select Country

* Green Card Id:

* Type of Government Issued ID:
* Enter the ID:

* Date of Birth:
SSN
“(Disclosure of your Social Security Number is not mandatory. The Agency for Health Care Administration may request your Social Security Number pursuant to Section 119.071, Florida Statutes.)”

* Are you requesting authorization to change and maintain the recipients managed care plan(s) and/or change and maintain the recipients demographic information?
Change and maintain the recipient's managed care plan(s).
Change and maintain the recipient's demographic information.

  Next Close

"Lose all their progress to add the recipient, and are they sure they want to cancel?”
Yes No

WARNING:

If you knowingly and willfully request or obtain any record concerning a Medicaid Recipient under false pretenses, you shall be guilty of a misdemeanor and fined not more than $5,000. 5 U.S.C.§552a(i)(3).

I declare under penalty of perjury under the laws of the State of Florida that the foregoing is true and correct.
* Contact Method:
Select Option Email Phone number

* Email Address:

* Phone Number:

WARNING:

If you knowingly and willfully request or obtain any record concerning a Medicaid Recipient under false pretenses, you shall be guilty of a misdemeanor and fined not more than $5,000. 5 U.S.C.§552a(i)(3).

I declare under penalty of perjury under the laws of the State of Florida that the foregoing is true and correct.