STATE OF FLORIDA E AGENCY FOR HEALTH CARE ADMINISTRATION ! ki i. 2819 shy AMERISURE MUTUAL | INSURANCE COMPANY, VISION ge J His TRATI VE Petitioner, DOAH CASE NO. 07-1668.8/863 °° AHCA NO. 2007003870 v. DETERMINATION NO. 20070122-004 STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Respondent. : / FINAL ORDER THIS CAUSE concerns a Petition for Administrative Hearing (“Petition”) that the Petitioner filed on March 16, 2007. On April 11, 2007, the Petition was forwarded to the Division of Administrative Hearings by the Agency and assigned to an Administrative Law Judge (“ALJ”). On November 14, 2007, the Petitioner filed a Notice of Voluntary Dismissal, stating that the reimbursement dispute was resolved. On November 19, 2007, the ALJ assigned to the case entered an Order Closing File, relinquishing jurisdiction back to the Agency. Based upon the foregoing; TIS THEREFORE ORDERED AND ADJUDGED THAT: The Petitioner’s Petition is dismissed with prejudice and the Agency’s February 21, 2007, Determination is hereby upheld. Unless they have already done so, Petitioner shall submit the correct reimbursement amount as stated in the Agency’s February 21, 2007, Determination to Orlando Regional Healthcare within 30 days of the date that this final order is rendered, and shall submit proof of reimbursement to: Ms. Twan Jackson, Workers’ Compensation Medical Services Unit, c/o Department of Financial Services, 200 East Gaines Street, Tallahassee, Florida 32399- 4232. Petitioner shall govern itself accordingly. DONE and ORDERED this Nodkdsay of -__, 2008, in Tallahassee, aks BENSON, sfeze Z AGENCY FOR HEALTH CARE ADMINISTRATION Florida. NOTICE OF RIGHT TO JUDICIAL REVIEW A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO JUDICIAL REVIEW, WHICH SHALL BE INSTITUTED BY FILING THE ORIGINAL NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A COPY ALONG WITH THE FILING FEE PRESCRIBED BY LAW WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF THE RENDITION OF THE ORDER TO BE REVIEWED. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing Final Order has been furnished by U.S. or interoffice mail to the persons named below on this / 7 BA say of Jure—, 2008. RICHARD J. SHOOP, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 (850) 922-5873 COPIES FURNISHED TO: Carolyn S: Holifield Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 Mari H. McCully, Esquire Department of Financial Services Division of Workers’ Compensation 200 East Gaines Street Tallahassee, Florida 32399-4229 Cindy R. Galen, Esquire Eraclides, Johns, Hall, Gelman, Eikner and Johannessen, L.L.P. 2030 Bee Ridge Road Sarasota, Florida 34239 Orlando Regional Healthcare Post Office Box 620000, Stop 9936 Orlando, Florida 32891 Jan Mills . Facilities Intake Elizabeth Dudek Health Quality Assurance Orlando Regional Healthcare System 3090 Caruso Court Orlando, Florida 32806

Docket for Case No: 07-001663