FL RW Portal

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*

Mailing Address*

City*

State*

Zip Code*

County

Since your initial certification or annual recertification one year ago, have you changed your home address? *

No, my address has not changed.

Yes, my address has changed.

*If your current home address has changed from your last certification, please provide documentation to determine if this change affects your eligibility for RWP A or B services.

Living Arrangement

Since your initial certification or annual recertification one year ago, has your living arrangement changed? *

No, my living arrangement has remained the same.

Yes, my living arrangement has changed.

Select current living arrangement:

Stable/permanent (own home, renting, HOPWA-funded housing assistance, Section 8 housing, public housing, etc.)

Temporary (transitional housing, temporarily living with family or friends, hotel or motel paid without a voucher, etc.)

Unstable (emergency shelter, hotel or motel paid with a voucher, homeless, prison, jail, etc.)

*If your current living arrangement has changed from your last certification, please provide documentation to determine if this change affects your eligibility for RWP A or B services.

Household Income (Includes income of spouse and dependents, if applicable)

Current Household Size

Current Household Income (Monthly or Annually)

Since your initial certification or annual recertification one year ago, has your income or household size changed? *

No, the income and household size has remained the same.

Yes, the income AND/OR household size has changed.

*If your current household size and/or income has changed, please provide documentation to determine if this change affects your eligibility for RWP A or B services.

Insurance Status

Since your initial certification or annual recertification one year ago, has your insurance status changed? *

No, my insurance status has remained the same.

Yes, my insurance status has changed.

Select current insurance status:

Medicaid

Child Health Insurance Program (CHIP)

Medicare (A, B, C or D)

ACA/Marketplace Health Plan

Employer-Sponsored Health Insurance1

Other Private Insurance

No Insurance

*If your current insurance status has changed, please provide documentation to determine if this change affects your eligibility for RWP A or B services

The information provided by me above is true, accurate and complete to the best of my knowledge. I understand that providing false information may disqualify me from receiving RWP A or B services. I also understand that RWP A and B cannot pay for services that have been paid or can reasonably be paid by any other source (e.g., state, federal or private entity) that provides the same health benefits or services.

In-person certifications must be signed by the client/legal representative and staff. Certifications not made in person (phone, email, mail, etc.) must include the name, signature and agency name of the staff member completing the form.

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

Client Eligibility Update Form