Health Quality Assurance Licensure Forms

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

Licensure Forms For All Applicants As Required By Law

Select a provider type to view its licensure forms:

Abortion Clinic
Abortion Referral or Counseling Agency
Adult Day Care Center
Adult Family Care Home
Ambulatory Surgical Center
Assisted Living Facility
Birth Center
Clinical Laboratory
Drug Free Workplace Lab

Health Care Clinic
Health Care Clinic Exemption from Licensure
Health Care Risk Manager
Health Care Services Pool
Home Health Agency
Home Medical Equipment Provider
Home for Special Services

Homemaker & Companion Services Provider
Hospice
Hospital
Intermediate Care Facility
Mental Health Services:CSU/SRT/RTF
Multiphasic Health Testing Ctr
Nurse Registry

Nursing Home
Organ Procurement/ Tissue Bank/ Eye Bank
Prescribed Pediatric Extended Care Center
Residential Treatment Centers for Children and Adolescents
Transitional Living Facilities

Submit Online - Providers can submit renewal and change during licensure period applications through the Agency's Online Licensing System. indicated below.

To avoid having your application or fees returned:

Licensure Forms
PROVIDER TYPE RECOMMENDED FORMS FORMS AUTHORIZED BY RULE
Abortion Clinic
(Abortion Clinic webpage)

 

Abortion Clinic Application Form [111KB, DOCX]
Abortion Clinic Application Checklist [53KB, DOCX]
Health Care Licensing Application Addendum [125KB, DOC]
Abortion Clinic Incident Reporting Form [74KB, DOCX]
Refusal to Permit Administration of Rho(D) Immune Globulin Form [49KB, DOCX]
Attestation of Compliance with Background Screening Requirements [173KB, DOC]
DOH Approval of onsite sewage disposal systems [PDF]
Clinical Laboratory Application Form [184KB, DOC]
ITOP Provider Enrollment User Agreement [52KB, PDF]

Abortion Referral or Counseling Agency
(Hospital and Outpatient Services webpage)

 

Abortion Referral or Counseling Agency Registration Form [72KB, DOCX]
Abortion Referral or Counseling Agency Checklist [44KB, DOCX]

Statute/Rule Authority
Section 390.025, Florida Statute
Rule 59A-9.035, Florida Administrative Code

Adult Day Care Center
(Adult Day Care Center webpage)

 

Adult Day Care Center Recommended Application Form [343KB, DOC]
Health Care Licensing Application Addendum [127KB, DOC]
Attestation of Compliance with Background Screening Requirements [173KB, DOC]
Proof of Financial Ability to Operate [431KB, XLS]
Specialty License Notification Form [75KB, DOC]
Specialty License Affidavit of Compliance [150KB, PDF]
ADCC Operator Identification [72KB, DOC]

 

AHCA Form 3180-1004 [321KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOC] AHCA Form 3100-0009 [361KB, XLS]

Adult Family Care Home
(Adult Family Care Home webpage)

 

Adult Family Care Home Recommended Application Form [240KB, DOC]
Health Care Licensing Application Addendum [127KB, DOC]
Attestation of Compliance with Background Screening Requirements [173KB, DOC]
Income and Expense Statement [34KB, PDF]
AFCH Local Zoning Form [37KB, PDF]

 

AHCA Form 3180-1022 [195KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOC]

Ambulatory Surgical Center
(Ambulatory Surgical Center webpage)

 

Ambulatory Surgical Center Application Form [501KB, PDF]
Ambulatory Surgical Center Application Form [137KB, DOCX]
Health Care Licensing Application Addendum [127KB, DOC]
Attestation of Compliance with Background Screening Requirements [173KB, DOC]
Clinical Laboratory Application Form [184KB, DOC]
Medicare Administrative Contractor Choice Form [190KB, PDF]
Health Insurance Benefit Agreement Form [PDF]
Request for certification in Medicare/Medicaid program [PDF]
Assurance of Compliance [PDF]
Medicare Enrollment Application [PDF]

Assisted Living Facility
(Assisted Living Facility webpage)

 

ALF Application Form [446KB, DOC]
ALF Application Checklist [121KB, DOC]
Proof of Financial Ability to Operate for ALFs with 16 or Less Beds [240KB, XLS]
ALF Notification of Change of Administrator [86KB, DOC]
Health Care Licensing Application Addendum [127KB, DOC]
Attestation of Compliance with Background Screening Requirements [173KB, DOC]
Proof of Financial Ability to Operate for ALFs with 17 or More Beds [408KB, XLS]

 

AHCA Form 3180-1006 [76KB, DOC]

Birth Center
(Birth Center webpage)

 

Birth Center Application Form [123KB, DOCX]
Birth Center Application Form[429KB, PDF]
Health Care Licensing Application Addendum [127KB, DOC]
Attestation of Compliance with Background Screening Requirements [173KB, DOC]
Clinical Laboratory Application Form [184KB, DOC]
DOH approval of onsite sewage disposal systems [PDF]

Clinical Laboratory
(Clinical Laboratory webpage)
(Non-Waived Lab webpage)

 

Clinical Laboratory Application Form [184KB, DOC]
Addition of Speciality Services Application [141KB, DOC]
Health Care Licensing Application Addendum [127KB, DOC]
Attestation of Compliance with Background Screening Requirements [173KB, DOC]
CLIA Application Form CMS-116 PDF

Drug Free Workplace Laboratory
(Drug Free Workplace Laboratory webpage)

 

Drug Free Workplace Lab Application Form [170KB, DOC]
Health Care Licensing Application Addendum [127KB, DOC]
Attestation of Compliance with Background Screening Requirements [173KB, DOC]

Health Care Clinic
(Health Care Clinic webpage)

 

AHCA 3110-0013, Health Care Clinic Licensure Application [150KB, DOC]
AHCA 3110-1028, Medical Clinic Director Attestation [33KB]
Health Care Licensing Application Addendum [127KB, DOC]
Proof of Financial Ability to Operate [361KB, XLS]
Attestation of Compliance with Background Screening Requirements [173KB, DOC]

Health Care Clinic Exemption from Licensure
(Health Care Clinic webpage)

 

AHCA 3110-0014, Health Care Clinic Exemption Application [132KB, DOC]

Health Care Risk Manager
(Risk Manager webpage)

 

Health Care Risk Manager Application Form [102KB, DOC]
Health Care Licensing Application Addendum [127KB, DOC]
Attestation of Compliance with Background Screening Requirements [173KB, DOC]
Verification of Experience [108KB, PDF]

Health Care Services Pool
(Health Care Services Pool webpage)

 

Health Care Services Pool Application Form [263KB, DOC]
Health Care Services Pool Application Form [4.06MB, PDF]
Health Care Licensing Application Addendum [127KB, DOC]
Attestation of Compliance with Background Screening Requirements [173KB, DOC]

Home Health Agency
(Home Health Agency webpage)

 

Home Health Agency Application Form [124KB, DOCX]
Home Health Agency Application Checklist [56KB, DOCX]
Health Care Licensing Application Addendum [127KB, DOC]
Attestation of Compliance with Background Screening Requirements [173KB, DOC]
Proof of Financial Ability to Operate [361KB, XLS]
Attestation of Compliance with Distance Requirements, AHCA Form 3110-1026 [46KB, DOCX]

Home Medical Equipment Provider
(Home Medical Equipment Provider webpage)

 

Home Medical Equipment Application Form [501KB, DOC]
Health Care Licensing Application Addendum [127KB, DOC]
AHCA Form 3110-1020, Request for Change of Name and/or Address [56KB, DOC]
Attestation of Compliance with Background Screening Requirements [173KB, DOC]
Proof of Financial Ability to Operate [361KB, XLS]

Home for Special Services
(Home for Special Services webpage)

 

Home For Special Services Application Form [262KB, DOC]
Health Care Licensing Application Addendum [127KB, DOC]
Attestation of Compliance with Background Screening Requirements [173KB, DOC]

Homemaker & Companion Services Provider
(Homemaker & Companion Services Provider webpage)

 

Homemaker & Companion Services Provider Application Form [109KB, DOCX]
Health Care Licensing Application Addendum [127KB, DOC]
Attestation of Compliance with Background Screening Requirements [173KB, DOC]

Hospice
(Hospice webpage)

 

Hospice Recommended Application Form [166KB, DOCX]
Health Care Licensing Application Addendum [127KB, DOC]
Attestation of Compliance with Background Screening Requirements [173KB, DOC]
Proof of Financial Ability to Operate [361KB, XLS]
Attestation of Compliance with Applicable Life Safety Codes for Additions to Existing Hospice Inpatient Facilities/Residential Units [59KB, DOC]

 

AHCA Form 3110-4001 [412KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOC]
AHCA Form 3100-0009 [361KB, XLS]

Hospital
(Hospital webpage)

 

Hospital Application Form [160KB, DOCX]
Health Care Licensing Application Addendum [127KB, DOC]
Attestation of Compliance with Background Screening Requirements [173KB, DOC]
Clinical Laboratory Licensure Application [184KB, DOC]
Burn Unit Services Licensure Application [53KB, DOC]
Adult Inpatient Diagnostic Cardiac Catheterization Licensure Application [55KB, DOC]
Level I Adult Cardiovascular Services [61KB, DOC]
Level II Adult Cardiovascular Services [61KB, DOC]
Stroke Center Affidavit [38KB, PDF]
Emergency Services Exemption Request Form [141KB, PDF]
ITOP Provider Enrollment User Agreement [52KB, PDF]
Medicare Enrollment Application [PDF]
Health Insurance Benefit Agreement Form [PDF]
Medicare Certification Civil Rights Information Request Form [PDF]
Assurance of Compliance [PDF]
Medicare Administrative Contractor Choice form [190KB, PDF]

Intermediate Care Facility for the Developmentally Disabled
(Intermediate Care Facility for the Developmentally Disabled webpage)

 

Health Care Licensing Application, ICF/DD [162KB, DOC]
Health Care Licensing Application Addendum [127KB, DOC]
Proof of Financial Ability to Operate [173KB, XLS]
Attestation of Compliance with Background Screening Requirements [173KB, DOC]

 

Mental Health Services -
(CSU / SRT webpage)
(RTF webpage)

 

Mental Health Services - CSU/SRT/RTF [137KB, DOCX]
Mental Health Services - CSU/SRT/RTF [264KB, PDF]
Health Care Licensing Application Addendum [127KB, DOC]
Attestation of Compliance with Background Screening Requirements [173KB, DOC]
DOH approval of onsite sewage disposal systems [PDF]
HIV/AIDS Training Affidavit [22KB, PDF]
Local Zoning Form (Levels I-A, I-B, and II) [32KB, PDF]

 

AHCA Form 3180-5003 [319KB, DOC]
AHCA Form 3180-5003 [267KB, PDF]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOC]

Multiphasic Health Testing Center
(Multiphasic Health Testing Center webpage)

 

Multiphasic Health Testing Center Application Form [132KB, DOC]
Health Care Licensing Application Addendum [127KB, DOC]
Attestation of Compliance with Background Screening Requirements [173KB, DOC]

Nurse Registry
(Nurse Registry webpage)

 

Nurse Registry Application Form [104KB, DOC]
Nurse Registry Application Checklist [55KB, DOC]
Health Care Licensing Application Addendum [127KB, DOC]
Attestation of Compliance with Background Screening Requirements [173KB, DOC]
Nurse Registry Proof of Financial Ability to Operate [179KB, XLS]

Nursing Home
(Nursing Home webpage)

 

Health Care Licensing Application Nursing Homes [157KB, DOC]
Medicaid Lease Bond [9KB, PDF]
Patient Trust Surety Bond [53KB, DOC]
Unconditional Guarantee of Payment [10KB, PDF]
Health Care Licensing Application Addendum [127KB, DOC]
Attestation of Compliance with Background Screening Requirements [173KB, DOC]
Proof of Financial Ability to Operate [173KB, XLS]
Gold Seal Application [63KB, DOC]

 

Organ Procurement / Tissue Bank / Eye Bank
(Organ Procurement / Tissue Bank / Eye Bank webpage)

 

Organ Procurement / Tissue Bank / Eye Bank Application Form [122KB, DOC]
Health Care Licensing Application Addendum [127KB, DOC]
Attestation of Compliance with Background Screening Requirements [173KB, DOC]

Prescribed Pediatric Extended Care Centers
(Prescribed Pediatric Extended Care Centers webpage)

 

Health Care Licensing Application, Prescribed Pediatric Extended Care Centers [113KB, DOC]
Health Care Licensing Application Addendum [127KB, DOC]
Attestation of Compliance with Background Screening Requirements [173KB, DOC]
Proof of Financial Ability to Operate [361KB, XLS]

Residential Treatment Centers for Children and Adolescents
(Residential Treatment Centers for Children and Adolescents webpage)

 

Residential Treatment Centers Recommended Application Form [130KB, DOCX]
Residential Treatment Centers Recommended Application Form [465KB, PDF]
Health Care Licensing Application Addendum [127KB, DOC]
Attestation of Compliance with Background Screening Requirements [173KB, DOC]
HIV/AIDS Training Affidavit [22KB, PDF]
Community Residential Home Affidavit of Compliance [36KB, PDF]
DOH approval of onsite sewage disposal systems [PDF]

 

AHCA Form 3180-5004[302KB, DOC]
AHCA Form 3180-5004 [465KB, PDF]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOC]

Transitional Living Facilities
(Transitional Living Facilities webpage)

 

Recommended Transitional Living Facilities Application Form [102KB, DOCX]

Transitional Living Facilities Application Form [270KB, DOC]
Health Care Licensing Application Addendum [127KB, DOC]
Attestation of Compliance with Background Screening Requirements [173KB, DOC]
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