AHCA Form 5000-3008 is the medical certification Florida requires before Medicaid will pay for nursing facility care or Home and Community-Based Services waiver programs. A physician, advanced registered nurse practitioner, or physician assistant completes the clinical sections; the applicant or a family member fills in identifying and demographic information; and the finished form goes to the Comprehensive Assessment and Review for Long-Term Care Services (CARES) program, which decides whether the applicant meets Florida’s nursing-facility level-of-care standard.
Where to Download the Form
The Agency for Health Care Administration publishes the 5000-3008 as a fillable PDF on its website.1Florida Agency for Health Care Administration. AHCA Form 5000-3008 – Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Florida Administrative Code Rule 59G-1.045 incorporates the form by reference.2Cornell Law Institute. Florida Code 59G-1.045 – Medicaid Forms Hospital discharge planners, nursing facility admissions coordinators, and Medicaid caseworkers can also provide copies.
Download the form before the doctor’s appointment. That way the clinical sections can be filled in during the visit rather than forcing a second trip.
What You Fill In
The top of page 1 asks for three required identifiers: the patient’s full name, the last four digits of the Social Security number, and the date of birth.3Florida Agency for Health Care Administration. Instructions for Completing the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form The form does not ask for the full SSN. If the applicant already has a Medicaid ID number, include it so AHCA can match the certification to the financial application.
Section A collects demographic information: gender, race, Hispanic ethnicity, and primary language.1Florida Agency for Health Care Administration. AHCA Form 5000-3008 – Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Every field marked with an asterisk is mandatory. Leaving one blank is the fastest way to have the form kicked back.
Other non-clinical sections you or admissions staff can complete:
- Section B, Sight and Hearing: note visual or auditory impairments.
- Section C, Decision Making Capacity: describe the patient’s current ability to make care decisions.
- Section D, Emergency Contact: names and phone numbers for at least one contact.
- Section H, Advance Care Planning: indicate whether there is a living will, health care surrogate designation, or DNR, and attach copies if available.
CARES reviewers check these entries against the clinical sections for consistency, so accuracy on the first pass saves time.3Florida Agency for Health Care Administration. Instructions for Completing the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form
What the Medical Provider Fills In
Most of the form is clinical. The treating physician’s office, a hospital discharge nurse, or a nursing facility’s clinical team completes sections E through T, covering diagnoses, infection control, risk alerts, pain, vitals, nutrition, treatments, physical function, mental status, and skin condition. Two of these carry the most weight with CARES reviewers, and it is worth knowing what they should say.
Diagnoses (Section E)
Section E asks for the primary diagnosis driving the need for long-term care, plus all other active diagnoses. If the patient is hospitalized, the clinician should list the primary discharge diagnosis, the reason for transfer, and any surgical procedures performed during the stay.3Florida Agency for Health Care Administration. Instructions for Completing the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form When a patient has multiple conditions, the one that most directly prevents independent living should be listed as primary. A single vague diagnosis is a common reason for denial.
Activities of Daily Living (Section S)
Section S documents the patient’s ability to eat, bathe, dress, transfer between bed and chair, use the toilet, and move around. The clinician marks each activity as full independence, needing some help, or total dependence. This section is the core of the level-of-care determination because it translates diagnoses into a concrete picture of what the person can and cannot do alone.4Florida Agency for Health Care Administration. Instructions for Completing the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form
Cognitive Status (Section U)
For dementia or Alzheimer’s patients, Section U should document specific behaviors that create a safety risk: wandering, inability to recognize dangers, or failure to manage basic self-care because of neurological decline. Memory loss alone doesn’t automatically qualify someone. The certification needs to show that the impairment creates a need for constant supervision or a protected living environment.
CARES will not process the level-of-care determination until every applicable clinical section is filled in.3Florida Agency for Health Care Administration. Instructions for Completing the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form
The Physician Signature in Section Y
Section Y gives the form its legal force. A Florida-licensed doctor of medicine or doctor of osteopathic medicine must sign, certifying that the patient requires nursing facility services or Medicaid waiver services in lieu of nursing facility placement.1Florida Agency for Health Care Administration. AHCA Form 5000-3008 – Medical Certification for Medicaid Long-Term Care Services and Patient Transfer An advanced registered nurse practitioner may sign if the certification falls within their scope of practice, and a physician assistant may sign if delegated authority by a supervising physician.3Florida Agency for Health Care Administration. Instructions for Completing the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form
Section Y requires an original handwritten signature, printed name, title, Florida medical license number, contact phone number, and the effective date of the medical condition.3Florida Agency for Health Care Administration. Instructions for Completing the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form Stamped signatures are not accepted. A missing date or missing license number will get the entire package rejected. Section Z is a separate space for the name and contact information of whoever physically completed the form, which is often a nurse or case manager rather than the signing practitioner.
Hospital Transfer Attachments
When a patient is transferring from a hospital to a nursing facility, the 5000-3008 doubles as a transfer document. Sections I and J capture the name, address, phone, and fax of both sending and receiving facilities, along with the admit date, discharge date and time, and the discharge nurse’s name.1Florida Agency for Health Care Administration. AHCA Form 5000-3008 – Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Section L covers pending labs and medications due near transfer. Section N lists the reports that must be physically attached:
- Physician’s orders
- Discharge summary
- Medication reconciliation and discharge medication list
- PASRR (Preadmission Screening and Resident Review) forms
- Treatment orders, including wound care instructions
- Lab reports, X-rays, EKG, MRI, and CT scan results
- History and physical
- Social and behavioral history
Missing even one attachment can delay admission. The PASRR forms deserve special attention: federal law requires preadmission screening for serious mental illness or intellectual disability before any Medicaid-funded nursing facility admission, and the form will not be processed without them. Hospital discharge planners typically assemble the package, but confirm every document is in it before the patient leaves.
What CARES Looks For
Florida recognizes two tiers of nursing facility care for Medicaid purposes: skilled and intermediate. Intermediate care requires 24-hour observation and the constant availability of medical and nursing treatment, though not at hospital or skilled-nursing intensity. To qualify, the services must be ordered by a physician, medically necessary given the patient’s health status, required daily or intermittently, and consistent with the nature and severity of the condition. The amount of care needed is not the deciding factor on its own; a person who needs modest but constant supervision can still qualify.5Agency for Health Care Administration. Florida Code 59G-4.180 – Intermediate Care Services
State criteria must also provide access to individuals who meet federal coverage requirements.6Medicaid. Nursing Facilities In practice, CARES reviewers focus on how many Activities of Daily Living the applicant cannot perform independently. Dependence in bathing, dressing, eating, toileting, and mobility, especially when two or more require hands-on help, substantially raises the likelihood of meeting the threshold. Cognitive impairments that create safety risks carry similar weight even when physical limitations are less severe.
Submitting the Form
The completed 5000-3008 goes to the CARES program, which operates under the Florida Department of Elder Affairs.7Florida Department of Elder Affairs. Comprehensive Assessment and Review for Long-Term Care Services (CARES) Program Managed care plans submitting on behalf of enrollees send the form to CARES along with any additional referral documentation.8Agency for Health Care Administration. Statewide Medicaid Managed Care Contract Interpretation 2022-01 – Transition of Care CARES offices are organized by region, and the Department of Elder Affairs publishes a CARES Map and Directory listing each local office’s phone and fax. Nursing facility admissions staff and hospital discharge planners routinely submit by secure fax or electronic portal, but applicants or families can submit directly to the local CARES office.
Keep a copy of the signed and dated form. If CARES reports it never received the submission, your dated copy is the only proof you have.
After You Submit
A CARES registered nurse or assessor reviews the clinical data and completes an assessment of the applicant at no cost.7Florida Department of Elder Affairs. Comprehensive Assessment and Review for Long-Term Care Services (CARES) Program A CARES physician or registered nurse then determines the appropriate level of care. The recommendation is for the least restrictive placement that can meet the person’s needs, which means Home and Community-Based Services may be recommended in place of a nursing facility.
A CARES representative may contact the applicant or visit in person to verify that the functional limitations on the form match the applicant’s actual condition. Expect specific questions: can the person bathe without help, prepare a meal, manage medications, get in and out of bed? The representative is comparing what the form says to what they observe.
The applicant then receives a written notice approving or denying the level-of-care certification. Approval lets the financial side of the Medicaid application move toward final authorization. A denial notice must include instructions for filing a Medicaid fair hearing and the deadline.9Florida State Medicaid Managed Care. Medicaid Fair Hearing For Medicaid programs, the fair hearing request must be filed within 90 days of the notice.10Florida DCF. Appeal Hearings AHCA has jurisdiction over fair hearings involving denial of a requested service and reduction or termination of a previously authorized service.11Agency for Health Care Administration. Florida Code 59G-1.100 – Medicaid Fair Hearings
If the denial was based on thin documentation rather than a real disagreement about the patient’s condition, ask the physician to supplement the clinical sections and resubmit. A form denied because Section S lacked detail or Section E listed only a vague diagnosis can often be corrected and refiled faster than a hearing can be scheduled.