STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION XL INSURANCE COMPANY, Petitioner, STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Respondent. FILED Ba Y OLERY 103 tv 2008 JUN 17 af Ni Ib Ai Sy Vv Sit HOOF AGeIMlSTRATIY ve DOAH CASE NO. 07- 1736! JEARINGS AHCA NO. 2007004032 DETERMINATION NO. 20070216-016 FINAL ORDER THIS CAUSE concems a Petition for Administrative Hearing (“Petition”) that the Petitioner filed on April 5, 2007. On April 18, 2007, the Petition was forwarded to the Division of Administrative Hearings by the Agency and assigned to an Administrative Law J udge (“ALJ”). On May 25, 2007, the Petitioner filed a Notice of Voluntary Dismissal with Prejudice, stating that the parties had resolved the dispute. On May 30, 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 March 5, 2007, Determination is hereby upheld. Unless they have already done so, Petitioner shall submit the correct reimbursement amount as stated in the Agency’s March 5, 2007, Determination to North Florida Regional 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 JD day of Start ; 2008, in Tallahassee, Florida. ; Ne ee HOLLY BENSON, Secretary AGENCY FORJHEALTH 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 /6 _ day of Yen —, 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: Don W. Davis Administrative Law Judge Division of Administrative Hearings Mari H. McCully, Esquire Department of Financial Services Division of Worker’s Compensation The DeSoto Building 200 East Gaines Street 1230 Apalachee Parkway Tallahassee, Florida 32399-4229 Tallahassee, Florida 32399-3060 ; Timothy L. Newhall, Esquire Jan Mills Stiles, Taylor & Grace, P.A. Facilities Intake Post Office Box 1140 Tallahassee, Florida 32302 . North Florida Regional Center Elizabeth Dudek c/o HCA Health Quality Assurance 355 Crossing Boulevard Orange Park, Florida 32Q73 Broadspire Services, Inc. Post Office Box 25102 Lehigh Valley, Pennsylvania 18002-5102 Medical Analysis & Review Services FairPay Solutions 14295 Midway Road Suite 300 Addison, Texas 75001

Docket for Case No: 07-001756