HomeMy WebLinkAbout0267 AI~lBNDID NOTICE
SPATE OF FLORIDA
• DEPARTMENT OF HFIILTH AND REHABILITATIVE. SERVICES
MEDICAID ELIGIBILITY
• NOTICE OF CASF. ACTION - CHANCE/CANCELLATION
Fogey Meeeer(Legal tkln. forj
NAME Concertina Nardelli DATE MAILED April 22, 1980 (
ADDRESS 700 Virginia Avenue _ SOCIAL SECURITY { 148-12-1909
Ft. Pierce, FL 33450 MEDICAID ID{_ A66 09 56 009506302-1
Prog. Dist. Co. Fas11y 3SN
PROVIDEAFjSter Manor Nursing Home '
LEVEL/TYPE OF CARE Int. I COUNTY OF RESIDENCE St. Lucie/5!i UNIT { 37
Based on the information provided and in accordance with Florida Statutes, Chapter- {09, and Florida
Aaministrative Codes, Chapter lOC-8, Medicaid Eligibility, the following action has been taken as
indicated below:
C:!Pe.`IGE:
There has been a CtL4NCE in your Institutional Care Payment fran $ to $
with a daily rate of $ beginning an continuing until further notice.
You are responsible for paying torar s your cost of care after retaining
$ from you income or your personal needs. The reason(s) for the change is given
be ow.
You are eligible for an additional Medicaid benefit, under the Institutional Care Program. A
monthl}~ vendor payment in the amount of 5 with a daily rate of 5 has
been authorized for your cost of care beginning and continuing unti urt er notice.
You are responsible for paying S tower s your cost of care after retaining
S from your income or your personal needs. -
Supplement Payment(s) authorized as indicated below.
Supplement Month Adjusted Your Adjusted Number Adjusted A justed Vendor
Monthl Rate Res nsibilit of Da s Dail Rate Pa ent Amount
~ ~ 48'7894
~ I ~ 1950 .aY-2~ ~k~ 36
~~,r F: cur~k.u
lt06ER PCtTRAS
CANCELLATION7: t"LElt){ CSRCUIT CCUR n
ill}
Your Medicaid benefits have been CANCELLED effective (~/j/RQ fbt•tiE~ason~(s) q! bTw:
j Your Institutional Care vendor payment has been CANCELLED effective 6 / 1/$0 for the reason(s)
given below. The final payr.,ent information is:
Month Final Ua~ly Rate N• er Your F1na1
Monthl Rate of Da s Res nsibilit Vendor Pa .ent
The determination of your e L gibi~it•,• for assistance is based upon the provisions of Florida Administra-
tive Codes 10C-8.11 - lOC-8.19. Your benefits are being changed or cancelled as indicated above in
~ accordance with rule nu.~nber(s)
as defined on the reverse side o t is orm. -
Rear.:~n/Remarks: MrB. Nardelli'a resources exceed the amount allowed under the provision
of Title XVI nor that we caa• no longer exclude her home property as her principal
place of residence.
) - - If y u have reason to believe tnat this action is incorrect, your Payments Norker rill be glad to dis-
'ca~it with you; and you have the right to request a hearing before a State Hearings Officer. A
request for a hearing should be Wade within 30 days (but na later than 90 days) from the date at the
top of this notice. If you are currently receiving assistance and request a hearing within 10 days
from the date of this notice, benefits will continue at the current level through the month the hearing
~ 3ecision is reached. However, if the decision of the Hearings Officer is not in your favor, you may
be required to repay the continued benefits for which you were not eligible. You can bring with you
or to represented at the hearing by a lawyer, relative, or any person designated by you.
The address and telephone number of your local office is:
s
n
i l - 1 j
Payments Worker PAVE
Diaae Lenartiei~e, Unit 37 gpp~( ff~irr Av
t!RS-S £.S FORH 2233, IUIY 78 Replaces DFS-AP-730 which is obsolete)
y. - ,
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