"Monthly Certification of Eligibility for Title Xix Proprietary Adult Day Care Centers - Adult Care Food Program" - Florida

Monthly Certification of Eligibility for Title Xix Proprietary Adult Day Care Centers - 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 May 1, 2009;
  • The latest edition currently provided by the Florida Department of Elder Affairs;
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Department of Elder Affairs
ADULT CARE FOOD PROGRAM
Contract # _____________
Report Month ____________
MONTHLY CERTIFICATION OF ELIGIBILITY
FOR
TITLE XIX PROPRIETARY
ADULT DAY CARE CENTERS
I, hereby, certify that each private for-profit Adult Day Care Center listed below received compensation,
from amounts granted to the state under Title XIX of the Social Security Act, for at least 25 percent of its
enrolled adults, or the license capacity for each facility.
I further certify, that the attached Monthly Reimbursement Voucher does not include any meals in any for-
profit center for which the center received such compensation for less than 25 percent of its enrolled
adults or license capacity during this reporting month. *
* Center(s) approved for split shifts must have 25 percent of enrolled adults eligible for Title XIX benefits.
NAMES OF ACFP APPROVED CENTERS ELIGIBLE
TOTAL
TOTAL
CENTER’S
THIS REPORT MONTH
NUMBER OF
NUMBER OF
LICENSED
TITLE XIX
ADULTS
CAPACITY
ADULTS
ENROLLED
ENROLLED
Name and Address of ACFP Provider:
______________________________________________________________________
________________________________________________________
________________________________________________________
___________________________________
________________
____________
Signature of Authorized Provider Representative
Title
Date
Internal Management Document for use by DOEA staff, contractors and subcontractors.
M:\acfp-current\CD\2011\ Monthly Certification of Title XIX Eligibility
Rev. 5/09
Department of Elder Affairs
ADULT CARE FOOD PROGRAM
Contract # _____________
Report Month ____________
MONTHLY CERTIFICATION OF ELIGIBILITY
FOR
TITLE XIX PROPRIETARY
ADULT DAY CARE CENTERS
I, hereby, certify that each private for-profit Adult Day Care Center listed below received compensation,
from amounts granted to the state under Title XIX of the Social Security Act, for at least 25 percent of its
enrolled adults, or the license capacity for each facility.
I further certify, that the attached Monthly Reimbursement Voucher does not include any meals in any for-
profit center for which the center received such compensation for less than 25 percent of its enrolled
adults or license capacity during this reporting month. *
* Center(s) approved for split shifts must have 25 percent of enrolled adults eligible for Title XIX benefits.
NAMES OF ACFP APPROVED CENTERS ELIGIBLE
TOTAL
TOTAL
CENTER’S
THIS REPORT MONTH
NUMBER OF
NUMBER OF
LICENSED
TITLE XIX
ADULTS
CAPACITY
ADULTS
ENROLLED
ENROLLED
Name and Address of ACFP Provider:
______________________________________________________________________
________________________________________________________
________________________________________________________
___________________________________
________________
____________
Signature of Authorized Provider Representative
Title
Date
Internal Management Document for use by DOEA staff, contractors and subcontractors.
M:\acfp-current\CD\2011\ Monthly Certification of Title XIX Eligibility
Rev. 5/09