FL ACCESS Florida Fax/Scanning Cover Sheet (2024)

State of Florida Department of Children and Families ACCESS Florida Fax/Scanning Cover Sheet Use this cover sheet to fax or scan documents to the ACCESS Florida Program. For community partners state agencies or organizations that help ACCESS customers apply/reapply for benefits please use a separate cover sheet for each customer you help. Please give us as much information as possible about the customer. Please write the customer s name on each piece of paper that is sent. Please do not send documents more than once. Customers may check their My ACCESS account after three days to confirm the document was received* What is this for For Application/Renewal please check this box For Reporting a change on an approved case please check this box or For Medical Bills to meet monthly share of cost please check this box. Web application/renewal/Change confirmation number if known Case Number if known Customer s Name DOB Customer s Social Security Number not needed if case or confirmation number was provided above What is being turned in Please check all that apply Application Paper Application Medicaid/Medicare Buy-In Application Interim Contact Form - Screening for Expedited Medicaid Appointment Sheet Identity Verification Legal/Court Documents Medical Records/Bills Income verification Asset Verification Household expenses Other or Comments From Organization if any Phone To if known Number of Pages Mission Protect the Vulnerable Promote Strong and Economically Self-Sufficient Families and Advance Personal and Family Recovery and Resiliency. Please write the customer s name on each piece of paper that is sent. Please do not send documents more than once. Customers may check their My ACCESS account after three days to confirm the document was received* What is this for For Application/Renewal please check this box For Reporting a change on an approved case please check this box or For Medical Bills to meet monthly share of cost please check this box. Customers may check their My ACCESS account after three days to confirm the document was received* What is this for For Application/Renewal please check this box For Reporting a change on an approved case please check this box or For Medical Bills to meet monthly share of cost please check this box. Web application/renewal/Change confirmation number if known Case Number if known Customer s Name DOB Customer s Social Security Number not needed if case or confirmation number was provided above What is being turned in Please check all that apply Application Paper Application Medicaid/Medicare Buy-In Application Interim Contact Form - Screening for Expedited Medicaid Appointment Sheet Identity Verification Legal/Court Documents Medical Records/Bills Income verification Asset Verification Household expenses Other or Comments From Organization if any Phone To if known Number of Pages Mission Protect the Vulnerable Promote Strong and Economically Self-Sufficient Families and Advance Personal and Family Recovery and Resiliency. .

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