ACCESS Florida Food, Medical Assistance and Cash

Common ACCESS Florida Forms

For a complete listing of DCF forms visit: http://www.dcf.state.fl.us/DCFForms/Search.aspx

General Program Forms

ACCESS Florida Application (including Rights and Responsibilities and Personal Health Information Policy (HIPAA)) (Español)   (Kreyòl) Change Report Form Verification of Dependent Care Expenses (Español)   (Kreyòl) Verification of Employment/Loss of Income (Español)   (Kreyòl) Verification of Shelter Expenses (Español)   (Kreyòl) Financial Information Release (English and Español) (Kreyòl) Hearings Request for Public Assistance   (Español)   (Kreyòl) Child Support Cooperation Notice   (Español)   (Kreyòl) Child Support Cooperation Good Cause / Refusal to Cooperate   (Español)   (Kreyòl) Rights and Responsibilities   (Español)   (Kreyòl) Sample Fax Cover Sheet

Food Assistance Program Forms

Authorized Representative Designation   (Español) Food Stamp Work Registration Notice   (Español)   (Kreyòl) Verification of Dependent Care Expenses (Español)   (Kreyòl)

Temporary Cash Assistance Program Forms

Drug Testing Information Acknowledgement and Consent Release Form (Español) (Kreyòl) School Verification   (Español)   (Kreyòl) Change Report Form Immunization Verification for Public Assistance Applicant Notice of Learnfare Requirements   (Español) Work Activity Referral   (Español)   (Kreyòl)

Medicaid Program Forms

Appointment of a Designated Representative   (Español)   (Kreyòl) Informed Consent Long Term Care Assessment   (Español)   (Kreyòl) Medical Certification for Nursing Facility (Page 2) Patient Transfer and Continuity of Care (Page 2) Designation of Resources for Burial Funds Designation of Beneficiary Verification of Dependent Care Expenses (Español)   (Kreyòl) Assignment of Rights to Support for Institutional Care Program Life Insurance Verification Request Authorization to Disclose Information   (Español)   (Kreyòl)

ACCESS Florida Brochures and Department Publications

Community ACCESS Network Brochure ACCESS Florida Customer Brochure ACCESS Florida On-Line Web Application Tip Card Medically Needy Brochure  (Español)  (Kreyòl) SUNCAP  (Español)  (Kreyòl) TANF State Plan TANF Work Verification Plan Justice For All Poster ICP Brochure

ACCESS Florida Program Policy Manual

Policy Manual

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