AHCA Form 5240 006 – Florida Medicaid Unborn Activation Form

AHCA Form 5240 006 PDF Details

AHCA Form 5240 006, officially titled the Florida Medicaid Unborn Activation form, is used by pregnant women enrolled in Florida Medicaid to activate healthcare coverage for their unborn or newborn child. The Agency for Health Care Administration (AHCA) processes this form to create a separate Medicaid recipient ID for the baby, independent of the mother's coverage.

Who Needs to File AHCA Form 5240 006

This form is submitted by Florida Medicaid enrollees who are pregnant, their authorized representatives, or their healthcare providers. Managed care plans such as Sunshine Health, Staywell, and Humana also use this form to notify AHCA of a pending or completed birth. Filing is required to ensure the newborn receives uninterrupted Medicaid coverage from the date of birth.

Key Sections of the Form

The form collects the mother's Florida Medicaid ID, date of birth, and current mailing address. For the unborn or newborn child, it requests the estimated due date (or date of birth), gender, and birth weight if available. A signature field confirms the accuracy of the submitted information. A provider NPI number is required when a healthcare professional files on behalf of the beneficiary.

When to Submit the Form

Submit the completed AHCA 5240 006 form as early in the pregnancy as possible, and no later than 60 days after the birth. Late submissions can create a coverage gap that results in out-of-pocket costs for the delivery and initial newborn care. Newborns born to Medicaid-eligible mothers are presumptively eligible from birth, but activation must be formally requested within this window.

Common Mistakes to Avoid

Missing or incorrect Medicaid recipient IDs are the most frequent reason forms are rejected. All dates must follow the MM/DD/YYYY format. When activating coverage after the birth, include the baby's hospital birth record number if available. Do not leave the estimated due date field blank if the baby has not yet been born.

For related Florida healthcare and Medicaid forms, see AHCA Form 1823 (resident health assessment), AHCA Form 5000-3008 (Medicaid provider enrollment), and the BHSF Newborn Request Form required by some managed care plans.