Access Florida Fax – Fill Out and Use

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.

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

Other or Comments:

________________________________________________________________________

________________________________________________________________________

From: _________________ Organization (if any): _________________ Phone #: _____________

Mission: Protect the Vulnerable, Promote Strong and Economically Self-Sufficient Families, and

Advance Personal and Family Recovery and Resiliency