STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION PUBLIX SUPER MARKETS, INC., Petitioner, DOAH CASE NO. 07-1683 AHCA NO. 2007003762 DETERMINATION NO. 20070219-007 STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, L4:€ Hd 91 Yd¥ go Respondent. / “ feorriname me a FINAL ORDER s on e- THIS. CAUSE concerns a request for hearing (“Request”) that the Petitioner filed on March 29, 2007. On April 12, 2007, the Request was forwarded to the Division of Administrative Hearings by the Agency and assigned to an Administrative Law Judge (“ALJ”). On May 29, 2007, the Petitioner filed a notice of voluntary dismissal, stating that it no longer wished to proceed with a hearing on the matter. On May 31, 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 Request is dismissed with prejudice and the Agency’s March 9, 2007 Determination is hereby upheld. Unless it have already done so, Petitioner shall submit the correct reimbursement amount as stated in the Agency’s March 9, 2007 Determination to Terrell B. Bounds, M.D., P.A. within 30 days of the date that this final order is rendered, and shall submit proof of reimbursement to: Arlene Cotton, R.N., AHCA WC Med Services, Division of Worker’s Compensation, 200 East Gaines Street, Tallahassee, Florida 32399-4229. . Petitioner shall govern itself accordingly. DONE and ORDERED this A day of beet , 2008, in Tallahassee, Florida. HOLLY BENSON, Secretary 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 a furnished by U.S. or interoffice mail to the persons named below on this AS day of Fer 7, 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: Honorable William F. Quattlebaum Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 Vicki Belzer Publix Super Markets, Inc. Post Office Box 32016 Lakeland, Florida 33802-2016 Mari H. McCully, Esquire Department of Financial Services Division of Worker’s Compensation 200. East Gaines Street Tallahassee, Florida 32399-4229 Jan Mills Facilities Intake Elizabeth Dudek Health Quality Assurance

Docket for Case No: 07-001683