Health Facilities and Providers

The following licensure application forms are for use by health care providers regulated under Chapter 408, Part II, Florida Statutes. Forms are required pursuant to section 59A-35.060, Florida Administrative Code.

LICENSURE FORMS REQUIRED FOR ALL APPLICANTS AS APPLICABLE

NOTICE

Changes in law effective August 1 requires revisions to licensure application forms and fees for some provider types. The processing of level 2 background screening has also been revised for all applications.


Please use the recommended forms below when submitting an application for licensure.

The forms are interactive, unless otherwise noted, and may be filled out by typing into the form. When completed please print and mail the application and any supporting documents to the Agency.

Licensure applications and fees may be returned or delayed if submitted too early or certain items are missing.
Avoid having your application or fees returned by:

  • Including a check or money order with your application. (Fees must accompany the application).
  • Using a regular, pre-printed check. (Starter checks from new bank accounts are not accepted).
  • Making the check or money order payable to the Agency for Health Care Administration (AHCA).
  • Not submitting a renewal application more than 120 days before the expiration date.
  • For clinical laboratories – Do not send a check payable to CLIA.

 

 

FORMS USED BY PROVIDERS AS REQUIRED BY LAW

REQUIRED BY
RECOMMENDED FORM
Reflects changes in 2010 legislation
FORMS AUTHORIZED BY RULE
All Providers

Health Care Licensing Application Addendum (127 kb)

Affidavit of Compliance with Background Screening Requirements (102 kb)

AHCA Form 3110-1024 (126 kb)

AHCA Form 3100-0008 (126 kb)

Providers as required by law

Proof of Financial Ability to Operate (353 kb) AHCA Form 3100-0009 (353 kb)

HEALTH CARE LICENSING APPLICATIONS BY PROVIDER TYPE

REQUIRED BY
RECOMMENDED FORM
Reflects changes in 2010 legislation
FORMS AUTHORIZED BY RULE
Abortion Clinic Abortion Clinic Recommended Application Form (doc) (316 kb)
Abortion Clinic Recommended Application Form (pdf)(262 kb)
 AHCA Form 3130-1000 (311 kb)
Adult Day Care Center Adult Day Care Center Recommended Application Form
(326 kb)

Adult Day Care Center Operator Identification Statement
(65 kb)

Adult Day Care Local Zoning Form (72 kb)

Specialty License Notification Form (70 kb)

AHCA Form 3180-1004 (321 kb)


AHCA Form 3180-1036 (65 kb)

AHCA form 3180-1021 (72 kb)

Adult Family Care Home

Adult Family Care Home Recommended Application Form
(195 kb)

Adult Family Care Home Local Zoning Form (72 kb)

AHCA Form 3180-1022 (195 kb)


AHCA Form 3180-1021 (72 kb)
Ambulatory Surgical Center Ambulatory Surgical Center Recommended Application Form (doc) (368 kb)
Ambulatory Surgical Center Recommended Application Form (pdf) (391 kb)

AHCA Form 3130-2001 (354 kb)
Assisted Living Facility

Assisted Living Recommended Application Form (366 kb)

Proof of Financial Ability to Operate for ALFs with 16 or Less Beds (107 kb)

ALF Affidavit of Compliance Community Residential Home (102 kb)

Assisted Living Local Zoning Form (71 kb)

ALF Notification of Change of Administrator (76 kb)

AHCA Form 3110-1008 (355 kb)

Affidavit of Compliance (102 kb)

AHCA Form 3180-1021 (71 kb)

AHCA Form 3180-1006 (76 kb)
Birth Center Birth Center Recommended Application Form (doc) (329 kb)
Birth Center Recommended Application Form (pdf) (364 kb)		 AHCA Form 3130-3001 (327 kb)
Clinical Laboratory
(Non-Waived)

Clinical Laboratory Recommended Application Form (doc) (627 kb)
Clinical Laboratory Recommended Application Form (pdf) (1.28 MB)

Addition of Speciality Services Application, AHCA Form 3170-2004D (doc) (376 kb)
Addition of Speciality Services Application, AHCA Form 3170-2004D (pdf) (947 kb)

Initial Application, AHCA Form 3170-2004B (doc) (585 kb)
Initial Application, AHCA Form 3170-2004B (pdf) (914 kb)

CHOW Application, AHCA Form 3170-2004C (doc) (573 kb)
CHOW Application, AHCA Form 3170-2004C (pdf) (966 kb)

Renewal Application, AHCA Form 3170-2004 (doc) (570 kb)
Renewal Application, AHCA Form 3170-2004 (pdf) (710 kb)
Drug Free Workplace Laboratory Drug Free Workplace Lab Recommended Application Form (doc) (397 kb)
Drug Free Workplace Lab Recommended Application Form (pdf) (1.48 MB) 		AHCA Form 3170-5001 (348 kb)
Health Care Clinic Health Care Clinic Recommended Application Form (540 kb) AHCA Form 3110-0013 (384 kb)
Health Care Clinic Exemption for Licensure Health Care Clinic Exemption Recommended Application Form (294 kb) AHCA Form 3110-0014 (250 kb)
Health Care Risk Manager Health Care Risk Manager Recommended Application Form (doc) (196 kb)
Health Care Risk Manager Recommended Application Form (pdf) (171 kb)		 AHCA Form RM-001 (194 kb)
Health Care Services Pool Health Care Services Pool Recommended Application Form (292 kb) AHCA Form 3110-1010 (308 kb)
Home Health Agency Home Health Agency Recommended Application Form (464 kb) AHCA Form 3110-1011 (440 kb)
Home Medical Equipment Provider Home Medical Equipment Recommended Application Form (478 kb) AHCA Form 3110-1005 (481 kb)
Home for Special Services Home For Special Services Recommended Application Form (276 kb) AHCA Form 3110-3001 (278 kb)
Homemaker Companion Services Homemaker Companion Services Recommended Application Form (230 kb) AHCA Form 3110-1003 (227 kb)
Hospice Hospice Recommended Application Form (407 kb) AHCA Form 3110-4001 (412 kb)
Hospital Hospital Recommended Application Form (doc) (476 kb)
Hospital Recommended Application Form (pdf) (472 kb)
AHCA Form 3130-8001 (472 kb)
Intermediate Care Facility for the Developmentally Disabled ICF-DD Recommended Application Form (335 kb) AHCA Form 3110-5003 (333 kb)
Mental Health Services - CSU / SRT / RTF Mental Health Services - CSU/SRT/RTF
Recommended Application Form (doc)(326 kb)
Mental Health Services - CSU/SRT/RTF
Recommended Application Form (pdf) (265 kb)		 AHCA Form 3180-5003 (319 kb)
Multiphasic Health Testing Center Multiphasic Health Testing Center Recommended Application Form (doc) (336 kb)
Multiphasic Health Testing Center Recommended Application Form (pdf) (777 kb) 		AHCA Form 3170-4001 (327 kb)
Nurse Registry Nurse Registry Recommended Application Form (335 kb) AHCA Form 3110-7004 (322 kb)
Nursing Home

Nursing Home Recommended Application Form (402 kb)

Patient Trust Surety Bond (63 kb)

Medicaid Lease Bond not interactive (9 kb)

Unconditional Guarantee of Payment not interactive (10 kb)

AHCA Form 3110-6001 (399 kb)

AHCA Form 3110-6002 (63 kb)

AHCA Form 3110-6009 (9 kb)

AHCA Provider Form (10 kb)
Organ Procurement / Tissue Bank / Eye Bank Organ Procurement / Tissue Bank / Eye Bank
Recommended Application Form (doc) (335 kb)
Organ Procurement / Tissue Bank / Eye Bank
Recommended Application Form (pdf) (756 kb) 		AHCA Form 3140-2001 (323 kb)
Prescribed Pediatric Extended Care Centers Prescribed Pediatric Extended Care Centers
Recommended Application Form (280 kb)		 AHCA Form 3110-8002 (287 kb)
Residential Treatment Centers for Children and Adolescents Residential Treatment Centers Recommended Application Form (doc) (296 kb)
 AHCA Form 3180-5004 (302 kb)
Transitional Living Facilities Transitional Living Facilities Recommended Application Form (279 kb) AHCA Form 3110-9001 (281 kb)

Reporting Medicaid Fraud