ACCESS Florida Fax/Scanning Cover Sheet
[Pages:1]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 .
Who is this for? 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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