"Acfp Enrollment Roster - Adult Care Food Program" - Florida

Acfp Enrollment Roster - Adult Care Food Program is a legal document that was released by the Florida Department of Elder Affairs - a government authority operating within Florida.

Form Details:

  • Released on June 1, 2014;
  • The latest edition currently provided by the Florida Department of Elder Affairs;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Florida Department of Elder Affairs.

ADVERTISEMENT
ADVERTISEMENT

Download "Acfp Enrollment Roster - Adult Care Food Program" - Florida

Download PDF

Fill PDF online

Rate (4.8 / 5) 8 votes
Florida Department of Elder Affairs
Adult Care Food Program
ACFP Enrollment Roster
Institution Name:
Contract #
Facility Name:
Contract Approval Date (MM/DD/YY):
/
/
Participant’s Name
F
R
P
Participant’s Name
R
P
Title
Date
Category
Title
Date
Cate gory
F
Age
XIX
Enrolle d
Age
XIX
Enrolle d
(Last, First)
Change
(Last, First)
Change
Date
Date
1.
11.
2.
12.
3.
13.
4.
14.
5.
15.
6.
16.
7.
17.
8.
18.
9.
19.
10.
20.
Monthly:
Skipping those participants with a category change date from previous months, add the number of Free, Reduced-Price and Paid ON THIS PAGE that are enrolled during the month claimed.
Enter the category totals (F, R, P ) for the appropriate claim month in boxes below.
T o complete Monthly Claim for Reimbursement, add all Free, Reduced-Price and Paid page totals together.
O CT
NO V
DEC
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
F
F
F
F
F
F
F
F
F
F
F
F
R
R
R
R
R
R
R
R
R
R
R
R
P
P
P
P
P
P
P
P
P
P
P
P
(Enrollment Roster Instructions in Policy Manual and on Reverse)
Florida Department of Elder Affairs
Adult Care Food Program
ACFP Enrollment Roster
Institution Name:
Contract #
Facility Name:
Contract Approval Date (MM/DD/YY):
/
/
Participant’s Name
F
R
P
Participant’s Name
R
P
Title
Date
Category
Title
Date
Cate gory
F
Age
XIX
Enrolle d
Age
XIX
Enrolle d
(Last, First)
Change
(Last, First)
Change
Date
Date
1.
11.
2.
12.
3.
13.
4.
14.
5.
15.
6.
16.
7.
17.
8.
18.
9.
19.
10.
20.
Monthly:
Skipping those participants with a category change date from previous months, add the number of Free, Reduced-Price and Paid ON THIS PAGE that are enrolled during the month claimed.
Enter the category totals (F, R, P ) for the appropriate claim month in boxes below.
T o complete Monthly Claim for Reimbursement, add all Free, Reduced-Price and Paid page totals together.
O CT
NO V
DEC
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
F
F
F
F
F
F
F
F
F
F
F
F
R
R
R
R
R
R
R
R
R
R
R
R
P
P
P
P
P
P
P
P
P
P
P
P
(Enrollment Roster Instructions in Policy Manual and on Reverse)
ACFP Enrollment Roster
General Instructions
This is a required program record. Do not send the enrollment roster(s) or the attached Meal Benefit Income Eligibility Applications to the Adult Care Food Program (ACFP) office, unless
specifically requested by the State Agency. ACFP institutions may only claim reimbursement for reimbursable meals served to eligible, enrolled ACFP participants.
Once appropriately enrolled, each ACFP participant’s nam e w ill rem ain on the ACFP enrollm ent roster during the entire contract year.
Each new contract year requires new ACFP enrollm ent rosters.
Institutions must establish new rosters when their institution’s contract is approved/renewed, on or after the start of the new contract year (October 1). Each administered facility w ill maintain its
ow n set of ACFP enrollment rosters. Each roster page should be labeled w ith the name of the institution, institution’s ACFP contract number, name of the administered facility and the
institution’s contract approval date (month/day/year). All approved F&RP Meal Applications completed prior to or on the institution’s contract approval date w ill be sorted alphabetically, by
participant’s last nam e, and listed (enrolled) on the ACFP enrollment roster w ith the same enrollment date as the institution’s contract approval date.
Information should be transferred from each of the new ly approved or renew ing F&RP Meal Applications to the ACFP enrollment r oster. Enrollment rosters are used for tracking F&RP meal
eligibility and monthly ACFP participation activity. The number of ACFP participants, along w ith their category of eligibility, determines the rate of reimbursement. Care mus t be exercised w hen
transferring this information. A simple posting error, especially under the category of eligibility, may result in the institution’s receiving more or less reimbursement than actually earned.
Fill in all lines dow n the left-hand colum n, beginning w ith participant’s nam e, and then fill in all lines dow n the right-hand colum n. Com plete 1-10, then 11-20.
When page is full, follow the sam e procedure w ith subsequent pages.
All ACFP participants enrolled after the institution’s contract approval date w ill be listed in chronological order on the next available roster line. The participant’s enrollment date w ill be the
date the center representative signed and approved the application.
Each ACFP participant listed on the roster page w ill have an application attached behind that roster page, in the order in
w hich it appears on the roster (1-10, then 11-20).
When entering the participant’s inform ation on the ACFP enrollm ent roster, please print neatly and m ake certain to include:
ACFP participant’s name
(last name, first name)
Participant’s age
A check in the Title XIX column for those participants enrolled in a For Profit Center, w hose day program services are funded by Medicaid Waiver funds
Date of ACFP enrollment (month/day/year)
Category Change Date, if applicable (see criteria below)
A check identifying the participant’s eligibility category (Free, Reduced or Paid)
An enrolled participant’s category of eligibility m ay change due to the follow ing reasons:
Participant’s inability or refusal to re-certify zero income every month, resulting in expiration of Free Meal eligibility
A participant w ith a Free Meal application based on zero income stops attending participating center
If a participant’s category of eligibility changes after subm ission of the original F&RP Meal Application, the follow ing steps m ust be follow e d:
Obtain a new F&RP Meal Application w ith updated information.
Center representative w ill review for completeness, determine Free, Reduced-Price or Paid eligibility category, and approve and date application.
On the original enrollment form, fill in the Category Change Date column. The Categor y Change Date w ill be the same as the approval date on the new ly submitted F&RP Meal
Application.
On the next available line of the enrollment roster, re-enroll the participant. Use the same enrollment date as the new application’s approval date.
Place a check identifying the participant’s new eligibility category (Free, Reduced or Paid).
Internal Management Document for use by DOEA staff, contractors and subcontractors.
M:\\ACFP\2014 ACFP\2014 /EnrollmentRoster
Rev. 06/2014
Page of 2