Attachment F - Six Month Re-Determination Review Form - Florida Health

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Six Month Re-Determination Review Form
ATTACHMENT F
To be completed by eligibility staff to document applicant’s re-determination.
Re-Determination Date
Eligibility Staff Name
Client’s Name
Address
Please indicate any changes that have occurred, and attach appropriate documentation:
Change
No Change
Living in Florida
Participating in Other Social Service Programs
Income
The client has provided updated documentation for any items marked “change” and/or updated income
information where necessary. All employment income must be verified every six months.
Fill in the following information based on the re-determination:
Household Size
FPL
Income
Other Programs (list all that apply)

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