Request Form

AMF provides recommendations for complexed Medicaid Florida denied claims, EOB/remit explanations, Patient Billing Statements, UB04s and Revenue Cycle Services. We do NOT accept or approve Medicaid Florida applications. Most cases are resolved within 72 hours but could take up to 30 days. You will be notified via email when your case has been resolved. Please click here to learn more about our services.

Today's date

First name

Last name

Birthday

Month

Day

Year

Recipients ONLY

Which best describes you?

Reason for submission

Tax ID#

Hospitals ONLY

Phone

Facility Name

Hospitals ONLY

Multi-line address

Country/Region

Address

City

Zip / Postal code

Role

Hospitals ONLY

website

How may we help?

Upload up to 30 files

I am a Florida resident or hospital

Yes

I hereby authorize [Ask Medicaid Florida] to review, process, and securely store all submitted data for purposes of providing recommendations. I understand that my data will be protected under applicable privacy laws.

I certify that the information I have provided is true, accurate, and complete to the best of my knowledge. I affirm that I am the rightful owner of this information or have the legal authority to provide it on behalf of the individual named.

By signing below, I affirm that I agree with website Terms.

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Total Cost

$19.95