FL RW Portal

ReCertification Form

All fields/sections marked with (*) sign are required.

Select Language

Select Service County*

Select Agency

Eligibility Case Manager

Skip if you do not have or know your case manager

First Name*

Middle Name

Last Name*

Date of Birth*

Sex*

Primary Phone*

Alternate Phone

Mailing Address*

City*

State*

Zip Code*

County

Doctor's Name

Case Manager’s Name

Agency

Section 1- RESIDENCY

Have you moved/changed where you live? *

No, my address has not changed. (If no, go to Section 2: HOUSEHOLD SIZE.)

Yes, my address has changed. (If yes, please check the document type in the box below.)

Section 2- HOUSEHOLD SIZE

Has your household size changed? *

No, my household size has not changed.(If no, go to Section 3: INCOME.)

Yes, my household size has changed.(If yes, please check the document type in the box below.)

Marriage license/Domestic Partner registration form

Birth certificates

Adult living with client and claims the client as a dependent on taxes

Adult living with client and has legal custody of client

Tax return

Divorce decree

Death certificate

Section 3- INCOME

Has your income changed? *

No, my income has not changed.(If no, go to Section 4: HEALTH INSURANCE.)

Yes, my income has changed.(If yes, please check the document type in the box below.)

Copy of most recent pay stubs for the last month

Copy of most recent annual disability, SSI, retirement, pension, VA, child support/alimony, unemployment benefits, etc

Profit and Loss Statement from self-employment

Statement of no income

Three (3) months of bank statements

Client support letter

Other

Section 4- HEALTH INSURANCE

Has your insurance status changed? *

No, my insurance has not changed.

Yes, my insurance has changed.(If yes, please check the document type in the box below.)

Proof of Medicaid

Employer insurance verification

Current insurance benefits package information

Florida Medicaid Managed Information System (FLMMIS)

Medical Eligibility Verification System (MEVSNET)

Termination/Denial letter from employer

Termination/Denial letter from insurance Provider

Medicare

Federally Facilitated Marketplace

Section 5- ATTESTATION

Please attest to the following statement:

The information provided is true, correct, and complete to the best of my knowledge.
I understand that my records are protected under State and Federal laws and cannot be shared without my written consent.
I understand that information can be released for billing, chart audits, program monitoring/quality improvement, data reporting, and other purposes necessary to facilitate the provision of program services.
I also understand that I may change my consent at any time, in writing.

Communication:

Click here if you would like to receive email notifications on form updates. Please provide your email address in the field above.

Signature Date

System Support

FL RW Portal

ReCertification Form