Transfer and Change of Ownership Notice - Certificate of Exemption
Fee $100
The Certificate of Exemption issued to the current exempted entity is valid only for the owners and location for which it was originally issued. To report a transfer of ownership you must apply for an “Initial” certificate.
Select the link below and complete the application. Please read the instructions carefully. You must return the original health care clinic license or certificate of exemption issued to the facility, as required in Ch. 59A-33.010(2), F.A.C, and provide new ownership documentation.
Fee – A $100 fee applies. Make check or money order payable to AHCA. The agency does not accept starter checks.
APPLICATION AND INSTRUCTIONS (AHCA Form 3110-0014)
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