ae STATE OF FLORIDA — th AGENCY FOR HEALTH CARE ADMINISTRATION Petieye ERK 1008 208 LEN lig] Ge FFVA MUTUAL INSURANCE COMPANY, Petitioner, AHCA NO. 2007007206 v. DETERMINATION NO. 20070402-007 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 June 29, 2007. On July 18, 2007, the Petition was forwarded to the Division of Administrative Hearings by the Agency and assigned to an Administrative Law Judge (“ALJ”). On July 31, 2007, the Petitioner filed a Notice of Dismissal of Petition for Administrative Hearing, requesting that DOAH close its file. On August 1, 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 June 8, 2007, Determination is hereby upheld. Unless they have already done so, Petitioner shall submit the correct reimbursement amount as stated in the Agency’s June 8, 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_ {4 day of ae ; 2008, in Tallahassee, mie BENSON, Figg fe 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. TIFICATE OF SERVICE CER IT 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 day of Wee. 2008. SSO RICHARD J. SHOOP, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 (850) 922-5873 COPIES FURNISHED TO: Lawrence P. Stevenson Mari H. McCully, Esquire Administrative Law Judge Department of Financial Services Division of Administrative Hearings 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 Stiles, Taylor & Grace, P.A. Post Office Box 1140 Tallahassee, Florida 32302 Jan Mills Facilities Intake Medical Analysis & Review Services Fairpay Solutions 14295 Midway Road Suite 300 Addison, Florida 75001 Elizabeth Dudek Health Quality Assurance Orlando Regional Healthcare Post Office Box 620000, Stop 9936 Orlando, Florida 32891-9936

Docket for Case No: 07-003365