Extended Family Planning Services Recipient -
Denial Notice
Your application dated _______________ for extended family planning
benefits under a special Medicaid program has been DENIED as
of ______________ for the following reason(s):
Over income
Tubal ligation or hysterectomy
Services declined
Eligibility period expired
Other: ______________________________
We do want to encourage you to maintain your health by seeking health
care services through another organization. Your former doctor's
office may know of a plan that can fit your needs. You may also
contact your local county health department for free or reduced-cost
family planning services.
If you think that this action is incorrect or you disagree with a
decision, your local county health department eligibility worker or
your worker's supervisor will be glad to discuss it with you. You also
have the right to request in writing a hearing before a state hearings
officer. Requests for hearings must be filed with the agency clerk
within twenty-one (21) days of receipt of this notice. Written
requests must be sent to: Department of Health, Agency Clerk,
Office of the General Counsel, 4052 Bald Cypress Way, Bin #A-02,
Tallahassee, FL 32399-1703. You may bring with you or be represented
at the hearing by anyone you choose, such as a lawyer, relative or
friend. Your hearing will occur within ninety (90) days of the request.
In accordance with Federal law and our policy, the Department of
Health is prohibited from discriminating on the basis of race, color,
national origin, sex, age, disability, religion, political belief or
martial status.
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