STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION -ERK page! a na -] 1s li 42 FFVA MUTUAL, “pn i F , ie ioiOk OF ; AQMIMISTRATI YS Petitioner, DOAH CASE NO. 07-5414 HEARINGS AHCA NO. 2007013193 Vv. ; DETERMINATION NO. 20070830-004 STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Respondent, and HOLMES REGIONAL MEDICAL CENTER, INC., Intervenor. / FINAL ORDER THIS CAUSE concerns a Petition for Formal Administrative Hearing (‘Petition’) that the Petitioner filed on November 15, 2007. On November 28, 2007, the Petition was forwarded to the Division of Administrative Hearings by the Agency and assigned to an Administrative Law Judge (“ALJ”). On April 1, 2008, the Petitioner filed a Notice of Voluntary Dismissal, requesting that e DOAH close its file. On April 8, 2008, 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 24, 2007, Determination is hereby upheld. Unless they have already done so, Petitioner shall submit the correct reimbursement amount as stated in the Agency’s October 24, 2007, Determination to Holmes Regional 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 BP of Cee , 2008, in Tallahassee, Florida. it BENSON, i ? y 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 cL furnished by U.S. or interoffice mail to the persons named below on this S©— day of Vere , 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: T. Kent Wetherell, II 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 Worker’s Compensation 200 East Gaines Street Tallahassee, Florida 32399-4229 Timothy L. Newhall, Esquire Law Offices of Timothy L. Newhall, L.L.C. 1334 Timberlane Road, Suite 11 Tallahassee, Florida 32312 Jan Mills Facilities Intake Gigi Rollini, Esquire Elizabeth Dudek Holland & Knight, LLP Health Quality Assurance Post Office Drawer 810 Tallahassee, Florida 32302 Health First, Inc. Karin M. Byrne 3300 Fiske Boulevard : General Counsel’s Office Rockledge, Florida 32955 Medical Analysis & Review Services Fairpay Solutions, Inc. 14295 Midway Road Suite 300 Addison, Texas 75001

Docket for Case No: 07-005414