STATE OF FLORIDA : AGENCY FOR HEALTH CARE ADMINISTRA PTO 1008 WN 24 A I: ug TECHNOLOGY INSURANCE COMPANY AIVISION OF AND ASSOCIATED INDUSTRIES . ADMINISTRATIVE INSURANCE SERVICES, INC., HEARINGS Petitioner, DOAH CASE NO. 06-4903 AHCA NO. 2006010442 v. DETERMINATION NO. 20061013-001 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 November 21, 2006. On December 4, 2006, the Petition was forwarded to the Division of Administrative Hearings by the Agency and assigned to an Administrative Law Judge (“ALJ”). On January 11, 2007, the Petitioner filed a Notice of Voluntary Dismissal of Petition for Administrative Hearing, stating that the parties had resolved the dispute. On January 12, 2007, the ALJ assigned to the case entered an Order Closing File, relinquishing jurisdiction back to the Agency. Based upon the foregoing, IT IS THEREFORE ORDERED AND ADJUDGED THAT: The Petitioner’s Petition is dismissed with prejudice and the Agency’s October 21, 2006, Determination is hereby upheld. Unless they have already done so, Petitioner shall submit the correct reimbursement amount as stated in the Agency’s October 21, 2006, Determination to North Ridge Medical Center 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 Me aay of Qua , 2008, in Tallahassee, Florida. mA é BENSON, Kg Z AGENCY FOR HEALTH CARE ADMINISTRATION 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 Zs day of deren, 2008. COPIES FURNISHED TO: RICHARD J. SHOOP, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 (850) 922-5873 Ella Jane P. Davis 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 Tamela I. Perdue, Esquire Jan Mills Stiles, Taylor & Grace, P.A. Facilities Intake Post Office Box 1140 Tallahassee, Florida 32302 Fairpay Solutions, Inc. Elizabeth Dudek 14295 Midway Road, Suite 300 Health Quality Assurance Addison, Texas 75001 North Ridge Medical Center P.O. Box 740754 Atlanta, Georgia 30374

Docket for Case No: 06-004903