AHCA EVV Letter Sign-On Agreement
If your organization agrees with the content of the letter to the Agency for Health Care Administration (AHCA) to further delay the Medicaid Electronic Visit Verification mandate, please complete and submit the form below. By doing so, your organization will be listed as a cosigner of the letter, which will be submitted to AHCA Secretary Mary Mayhew on Friday, December 6, 2019. Cosigners will be listed as follows: "Full Name, Job Title, Organization".

The deadline to be included as a cosigner of the letter is Wednesday, December 4 at 5:00 p.m. ET.
Email address *
Home Health Agency Name *
Mailing Address *
Please include city, state, and ZIP code
AHCA License Number(s) *
If you have multiple state licenses, please list the AHCA license number and city in which the agency is located for each location
Who is the individual completing this form? *
Full Name and Title
What is the name of the individual who will sign the form? *
Full Name and Title
I agree that the individual named above and my organization support the content of the letter to AHCA and will be listed as a cosigner. *
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