11/21/2000 Verification
1Dannp lL. ltolbage
BRANCH OFFICE
3117 OVERSEAS HIGHWAY
MARA'I'HON, FLORIDA 33050
TEL. (305) 289-6027
FAX (305) 289-1745
CLERK OF THE CIRCUIT COURT
MONROE COUNTY
500 WHITEHEAD SlREET
KEY WEST, FLORIDA 33040
TEL. (305) 292-3550
FAX (305) 295-3660
BRANCH OFFICE
88820 OVERSEAS HIGHWAY
PLANTATION KEY, FLORIDA 33070
TEL. (305) 852-7145
FAX (305) 852-7146
MEMORANDUM
DATE:
December 15, 2000
TO:
Louis Latorre, Director
Social Services Division
ATIN:
FROM:
Jerry Eskew, Director
Transportation rt
Pamela G. Hanco
Deputy Clerk
At the November 21, 2000, Board of County Commissioners meeting the Board granted
approval of the Florida Medicaid Re-enrollment Facility Profile Verification between Monroe
County and the State of Florida, Agency for Health Care Administration for -the Transportation
.
Program.
Enclosed please find the original Re-enrollment for your handling. Should you have any
questions please do not hesitate to contact this office.
Cc: County Administrator w/o document
County Attorney
Finance
File /
004326
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RECEIVED
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AUG 4 2000
sr.P u 1 2000
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No
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: i F10r!da Medicai~ Re:en~~lIlI1ent';i~~!~~~;~~~(~~(r}~~~;$t::
FacIlIty Profile Venficatlon ...,.~,!;1." "'!'.:,'.".:'I"~,.,~'\~~I;i~!j,,.. "'.' '~i':':~'\;
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This is the information as it appears in your Provider File as of 06/2212000. Please
review and update if necessary using thespacep~~ided. J~~; 't;,',t:.: './\:,\4;~';~. ,:,
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MONROE CO BRD OF CO COMM . J' ..... ~
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TRANSPORTATION PROGRA. M . ,'>:.; l::::J-::..:..~. .'. '.' ..&.:.:.;.. .... ...........:...
5100 COLLEGE RD ,'.",.../. .j""< .........:autH.,~S:.ltCtvs:. tlg~
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KEY WEST FL ;".;'.;".~!~;, '. 1;' .;1\- :':':':':-r:_:~u::a';~gu.auu:o\.l:-
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KEY WEST FL 3304ci~~j;~.{;if4~.,;l,i~~..:i'~~ ::::::j${:::::';::::V::;::::I,,:::g::;:&::::::
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TRANSPORT A TrON PROGRAM, '.., .., ...............~.. .............
5100 COLLEGE RD ~} 1'~fIi../..?~:}~c;;iL'!.~. ~~~~~~~~~~~~!~!~!~!i!i~~~~~~~~!offi!?~~~~~~~!~~~i
KEY WEST, FL.33040,.-.+. '.,:;,j.i,,;T,;':,;> w, ':':':':':':':':':':-:':':':':'~~=Gj':-:':';":'-""",,:
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MONROE j,t" .l~ ,;j"',..JI".t>',,: '. ,,}. p' .".\ ,./f..' \'; ,,.. . .~,. ~'."g
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'i"";"~;;,,"~'~'f','1\!,:;,.,(Attach a copy of 55-4)
E=ELECTRONIC TRANSFER "J .:;, '.' . '(v' .........:...........................................................
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Background Screening! n;.i.~!j/'...)jji
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It is the responsibility of the provider to know the provisions' of Section 409,907, Florida
Statutes. and to be certain that the names and appropriate identifying informa'tion' for all
provider personnel on whom criminal history checks~re. required are submitted with this Profile
Verification. Please list below all partners or shareholders With ownership interest of five
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percent or more and all officers, directors, billing agents, and managers of this business. Use
an additional sheet if necessary. ..',~).I.lJ!:j..,,,.i.".~ ""., ",."., .',
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Print Each Name SSN License # 't.' % Own . ".Previous Background
E 2. QO.",a 2 4 (. ~/,,0:.:::screening Completed?
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_-.-=on..,....~-~~ I f":\ 0! m ~ nn n 1. f? ~ _ n m (;;'\ , .'f p~. I g:, :rYes _ _ .. . n No
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Payment Method
59-6000749
Telephone Number
Tax 10 Number
396 29~ 8466
County of Operation
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Correspondence Address
Payment Address
Business Address
(P.O. Boxes not accepted)
Doing Business As Name
Provider.Number and Type
Provider Name
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Verification:
DYes 0 No Have all partners or shareholders with ownership interest of five percent or more
and all officers, directors, billing agents, and managers submitted fingerprints
within the last 12 months for background screening as outlined in Section
409.907, Florida Statutes? If not then submit a completed fingerprint card
with a check for $39 made payable to Consultec for each person. Include
these cards and checks with your Profile Verification.
Dyes 0 No Do you provide services using a fully operational physician vehicle, unit, trailer
or office that travels to different locations for the provision of physician services
and is not a stationary physician unit or office? If yes, please attach a copy of
your contract with a county health department, federally qualified health
center, or rural health clinic and return with your Profile Verification.
DYes 0 No Have you attached proof of current bond coverage? This applies only to DME
and Home Health Agency providers. .
"
DYes DNo Has this facility had a change in ownership? If yes, give the date of change in
ownership.
o Check here if... all partners or shareholders with ownership interest of five percent or more and
all officers, directors, billing agents, and managers have signed the enclosed
Medicaid Provider Agreement. Please submit the original signed document
with your Profile Verification.
"
, \ I have reviewed this information and have made any necessary updates. I understand that it is
my responsibility to notify Medicaid's fiscal agent of any change to the information in my
provider file, including but not limited to, a change of address, group affiliation, ownership,
officers, directors, or tax identification number. All attachments required to update my file are
included with this re-enrollment packet.
I further understand that under Section 409.920(2)(f), Florida Statutes, the filing of materially
incomplete or false information with this re-enrollment verification is a third degree felony and
is SUffici:nt cause f~n from the Florida Medicaid Program.
~ed~nMUre
5u^tltlt"le. A, J~tt-OYl
Printed name of signatory above
OM" 1/01f/VV
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Title
The Final Step:
Mail your re-enrollment packet and any required attachments to the address below, If you have
any questions, please call the Consultec Enrollment Unit at 800-377-8216.
CONSUL TEC
Provider Enrollment
P.O. Box 13800
Tallahassee, FL 32317-3800
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004327
THE PARTIES AGREE THAT THIS AGREEMENT IS A LEGAL AND BINDING DOCUMENT AND IS FULLY
ENFORCEABLE IN A COURT OF COMPETENT JURISDICTION, THE SIGNATORIES HERETO REPRESENT AND
WARRANT THAT THEY HAVE READ THE AGREEMENT, UNDERSTAND IT, AND ARE AUTHORIZED TO EXECUTE
IT ON BEHALF OF THEIR RESPECTIVE PRINCIPALS'OR CO-OWNERS. THIS AGREEMENT BECOMES NULL AND
VOID UPON TRANSFER OF ASSETS; CHANGE OF OWNERSHIP; OR UPON DISCOVERY BY AHCA OF THE
SUBMISSION OF A MATERIALLY INCOMPLETE. MISLEADING OR FALSE PROVIDER APPLICATION UNLESS
SUBSEQUENTLY RATIFIED OR-APPROVED BY AHCA.
ALL PRINCIPALS, PARTNERS AND SHAREHOLDERS HAVING AN OWNERSHIP INTEREST OF FIVE PERCENT (5%)
OR GREATER ARE REQUIRED TO S1GN THIS AGREEMENT. FAILURE TO DO SO WILL MAKE THIS APPLICATION,
AGREEMENT AND PROVIDER NUMBER VOIDABLE BY AHCA,
FOR OFFICE USE ONLY
The provider's name is:
The facility's name is:
The provider number is:
IN WITNESS W,fiEREOF, the undersigned have caused this agreement to be duly executed under the penalties of
, . swealZOr affirm that the foregoing is true and correct.
Signature of Provider Date
(legibly print the above signature) Title
,-
Signature of Provider
Date
Signature of Provider
Date
(legibly print the above signature) Title
Signature of Provider
Signature of Provider
Date
(legibly print the above signature)
(legibly print the above signature) Title
Signature of Provider
Signature of Provider
Date
(legibly print the above signature) Title
(legibly print the above signature) Title
Signature of Provider
Date
Signature of Provider
Date
(USE ADDITIONAL PAGES IF NECESSARY)
MPA Revised July 191)<)
3
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