Florida Form CF-ES 2506A is the Client Referral/Change form that nursing facilities and Medicaid Long-Term Care managed care plans fax to the Department of Children and Families to open, update, or close a resident’s Medicaid eligibility file. You use it to report an admission that needs Institutional Care Program Medicaid, an LTC managed care plan enrollment or change, a transfer between facilities, a discharge, or a death. Complete the header, top sections, and Sections A and A1 for every submission, then add Section B, C, or D depending on the scenario, and fax the finished form to the local DCF office serving the facility.
Who Files It and When
Who prepares the form depends on the event being reported.
- Nursing facility completes the form when a resident has been admitted and needs Institutional Care Program Medicaid.
- LTC managed care plan or its case manager completes it for an initial LTC plan enrollment, a change from one LTC plan to another, or when someone already receiving community-based LTC services moves into a nursing facility.
- The LTC plan, case manager, or nursing facility reports a resident’s death.
- The LTC plan or case manager reports a transfer to another facility or a discharge.
One boundary to note before you start: if the resident is being discharged to a community setting where they will receive home and community-based waiver services, the 2506A is the wrong form. Use form 2515 instead. If a resident is transferring from one nursing facility to another, stay with the 2506A rather than the 2515.
Which Sections To Complete for Your Scenario
Every submission needs the Header, Top Left, Top Right, Section A, and Section A1. The variable is whether you add Section B, C, or D.
- Initial ICP Medicaid eligibility: add Section B.
- Community LTC enrollee moving into a nursing facility: add Section B.
- Initial LTC plan enrollment: add Section D.
- Change from one LTC plan to another: add Section D.
- Recipient discharge: add Section C.
- Recipient transfer or move to another facility: add Section C.
- Recipient deceased: add Section C.
Do not fill in sections that do not apply. Adding Section D when you are reporting a death, for example, muddies the action DCF is supposed to take.
Filling In Each Section
Header
Enter the DCF case number if the resident already has one on file with the department. For a resident who has never received DCF services, leave the case number blank; DCF will assign one when it processes the referral.
Top Left and Top Right
In the top left, enter the local DCF fax number you will use to send the form and the date you are submitting it. Fax numbers vary by county, so look up the number through the DCF service center locator before filling this in. In the top right, enter the name of the nursing facility or managed care plan submitting the form, a contact person’s name, that person’s phone number, and the full street address of the nursing facility where the resident lives.1Agency for Health Care Administration. CF-ES 2506A Referral Change Form Instructions
Section A — Resident’s Information
Enter the resident’s full legal name, Social Security number, date of birth, and Medicaid ID number. If the Medicaid ID is not yet known, which is common on an initial eligibility referral, leave that field blank. The SSN and date of birth are what DCF uses to match the referral to an existing record or create a new one, so accuracy here matters more than anywhere else on the form.
Section A1 — Representative Information
If the resident has an authorized representative such as a legal guardian, power of attorney, or a family member handling their affairs, list that person’s name, full mailing address, phone number, and relationship to the resident. DCF may contact this person to request eligibility documentation.
Section B — Admission and Eligibility
Use Section B when the resident needs ICP Medicaid or when a community LTC enrollee is moving into a nursing facility. Indicate whether the individual is an SSI direct enrollee, note the active aid category or coverage group, and enter the date the resident was admitted. Record where the resident lived before admission, including the prior residential address and, if applicable, the facility they came from.1Agency for Health Care Administration. CF-ES 2506A Referral Change Form Instructions
Section C — Discharge, Transfer, or Death
Use Section C for a discharge, transfer, or death. Record the date the event occurred. For a transfer, add the name and address of the receiving facility. For a death, enter the date of death. This section tells DCF to close or adjust the resident’s Medicaid eligibility.
Section D — Managed Care Plan Information
Use Section D for an initial LTC plan enrollment or a change from one LTC plan to another. Enter the effective date of the enrollment or change, the name of the managed care plan, and the plan’s designated representative, including their name, address, phone number, and email address. This is what routes claims to the right plan going forward.
How To Submit the Form
Fax the completed form to the local DCF office serving the county where the nursing facility is located. Fax numbers are county-specific; look up the correct one through the DCF service center locator or by contacting the regional DCF circuit office.1Agency for Health Care Administration. CF-ES 2506A Referral Change Form Instructions
If you cannot locate the right local number, DCF’s Office of Economic Self-Sufficiency Mail Center receives correspondence at P.O. Box 1770, Ocala, FL 34478-1770, and can be reached by fax at 1-866-886-4342. DCF headquarters in Tallahassee can direct you to the correct local contact at (850) 487-1111.2Florida Department of Children and Families. Contact Us
Confirm that the local fax number written on the form matches the number you are actually dialing. Save the fax confirmation page and keep a copy of the completed form in the resident’s facility file.
Mistakes That Cause Delays
- Sending the 2506A when form 2515 is required. If the resident is being discharged to community-based waiver services, use the 2515. DCF cannot process a discharge to waiver services on a 2506A.
- A wrong or missing Social Security number. A single transposed digit can create a duplicate record or leave the referral unmatched and unprocessed.
- Leaving off the DCF case number for a resident who already has one. This forces staff to search manually and slows the update.
- Faxing to the wrong DCF office. Each local office handles its own geographic area, and misrouted forms have to be forwarded internally before anyone acts on them.
- Filling in sections that do not belong to your scenario. Add only the sections listed for the event you are reporting.
What Happens After DCF Receives It
Eligibility staff review the referral and update the resident’s Medicaid file. On an initial ICP Medicaid referral, DCF may contact the nursing facility or the authorized representative for additional documentation such as proof of income, asset information, or identity verification. Respond promptly to keep the eligibility determination moving.
Plan changes and transfers generally process faster because the resident already has an active Medicaid record. Death notifications typically result in DCF closing the case after verifying the information. If the expected update does not appear in the Medicaid system, call the same local DCF office you faxed to check on the referral’s status.