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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.

Licensure Forms For All Applicants As Required By Law

Select a provider type to view its licensure forms:

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:

  • Make check/money order payable to Agency for Health Care Administration (AHCA), not State of Florida or CLIA.
  • Fees must accompany the application.
  • Renewal Applications must be submitted prior to expiration date but not more than 120 days before expiration.
Licensure Forms
PROVIDER TYPE RECOMMENDED FORMS FORMS AUTHORIZED BY RULE
Abortion Clinic
(Abortion Clinic webpage)

 

Recommended Abortion Clinic Application Form [111KB, DOCX]
Recommended Abortion Clinic Application Checklist [51KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]

 

AHCA Form 3130-1000 [111KB, DOC]
AHCA Form 3130-1000CL [53KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [178KB, DOCX]
Abortion Clinic Incident Reporting Form [74KB, DOCX]
Refusal to Permit Administration of Rho(D) Immune Globulin Form [49KB, DOCX]

Adult Day Care Center
(Adult Day Care Center webpage)

 

Recommended Adult Day Care Center Application Form [104KB, DOCX]
Recommended Adult Day Care Center Application Checklist [64KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, 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 [58KB, PDF]

 

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

Adult Family Care Home
(Adult Family Care Home webpage)

 

Recommended Adult Family Care Home Application Form [242KB, DOC]
Recommended Adult Family Care Home Application Checklist [60KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, 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, DOCX]

Ambulatory Surgical Center
(Ambulatory Surgical Center webpage)

 

Recommended Ambulatory Surgical Center Application Form [109KB, DOCX]
Recommended Ambulatory Surgical Center Application Checklist [51KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]

 

AHCA Form 3130-2001 [137KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX]

Assisted Living Facility
(Assisted Living Facility webpage)

 

Recommended Assisted Living Facility Application Form [450KB, DOCX]
Recommended Assisted Living Facility Application Checklist [121KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]
Proof of Financial Ability to Operate for ALFs with 16 or Less Beds [240KB, XLS]
Proof of Financial Ability to Operate for ALFs with 17 or More Beds [408KB, XLS]

 

AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX]
ALF Notification of Change of Administrator [86KB, DOC]

Birth Center
(Birth Center webpage)

 

Recommended Birth Center Application Form [103KB, DOCX]
Recommended Birth Center Application Checklist [51KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]

 

AHCA Form 3130-3001 [123KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX]

Clinical Laboratory
(Non-Waived Lab webpage)

 

CLIA Application Form CMS-116 PDF [ PDF]

Drug Free Workplace Laboratory
(Drug Free Workplace Laboratory webpage)

 

Recommended Drug Free Workplace Lab Application Form [119KB, DOCX]
Recommended Drug Free Workplace Lab Application Checklist [50KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]

 

AHCA Form 3170-5001 [169KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [169KB, DOCX]

Health Care Clinic
(Health Care Clinic webpage)

 

Recommended Health Care Clinic Licensure Application Form [120KB, DOC]
Recommended Health Care Clinic Licensure Application Checklist [46KB, DOC]
Recommended Health Care Licensing Application Addendum [141KB, DOC]

 

AHCA Form 3110-0013 [150KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [169KB, DOCX]
Medical Clinic Director Attestation [33KB, DOCX]
Proof of Financial Ability to Operate [361KB, XLS]

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

 

Recommended Health Care Clinic Exemption Application Form[80KB, DOC]
Recommended Health Care Clinic Exemption Application Checklist[50KB, DOC]

 

AHCA Form 3110-0014 [132KB, DOC]

Health Care Services Pool
(Health Care Services Pool webpage)

 

Recommended Health Care Services Pool Application Form [306KB, DOCX]
Recommended Health Care Services Pool Application Checklist [50KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]

 

AHCA Form 3110-1010 [263KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX]

Home Health Agency
(Home Health Agency webpage)

 

Recommended Home Health Agency Application Form [113KB, DOCX]
Recommended Home Health Agency Application Checklist [58KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]

 

AHCA Form 3110-1011 [124KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX]
Attestation of Compliance with Distance Requirements [46KB, DOCX]
Proof of Financial Ability to Operate [361KB, XLS]

Home Health Agency Exemption from Licensure
(Home Health Agency webpage)

 

Recommended Home Health Agency Exemption Application Form [89KB, DOCX]
Recommended Home Health Agency Exemption Application Checklist [50KB, DOCX]

Home Medical Equipment Provider
(Home Medical Equipment Provider webpage)

 

Recommended Home Medical Equipment Application Form [552KB, DOCX]
Recommended Home Medical Equipment Application Checklist [71KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]

 

AHCA Form 3110-1005 [501KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX]
AHCA Form 3110-1020, Request for Change of Name and/or Address [56KB, DOC]
Proof of Financial Ability to Operate [361KB, XLS]

Home for Special Services
(Home for Special Services webpage)

 

Recommended Home For Special Services Application Form [262KB, DOC]
Recommended Home For Special Services Application Checklist [96KB, DOC]
Recommended Health Care Licensing Application Addendum [141KB, DOC]

 

AHCA Form 3110-3001 [262KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX]

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

 

Recommended Homemaker & Companion Services Provider Application Form [107KB, DOCX]
Recommended Homemaker & Companion Services Provider Application Checklist [69KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]

 

AHCA Form 3110-1003 [109KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX]

Hospice
(Hospice webpage)

 

Recommended Hospice Application Form [127KB, DOCX]
Recommended Hospice Application Checklist [65KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]

 

AHCA Form 3110-4001 [166KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX]
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]

Hospital
(Hospital webpage)

 

Recommended Hospital Application Form [122KB, DOCX]
Recommended Hospital Application Checklist [54KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]
Recommended Health Care Licensing Application Alternate Site Testing, AHCA Form 3130-8013 [59KB, DOC]

 

AHCA Form 3130-8001 [160KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX]
Emergency Services Exemption Request Form [141KB, PDF]
Burn Unit Services Application [109KB, DOC]
Adult Inpatient Diagnostic Cardiac Catheterization Application[108KB, DOC]
Level I Adult Cardiovascular Services Application [116KB, DOC]
Level II Adult Cardiovascular Services Application [116KB, DOC]
Stroke Center Affidavit [113KB, DOC]

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

 

Recommended IFC/DD Application Form [109KB, DOC]
Recommended IFC/DD Application Checklist [68KB, DOC]
Recommended Health Care Licensing Application Addendum [141KB, DOC]

 

AHCA Form 3110-5003 [333KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX]
Proof of Financial Ability to Operate [173KB, XLS]

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

 

Recommended CSU/SRT Application Form [114KB, DOCX]
Recommended CSU/SRT Application Checklist [61KB, DOCX]
Recommended RTF Application Form [110KB, DOCX]
Recommended RTF Application Checklist [62KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]
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 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOC]

Multiphasic Health Testing Center
(Multiphasic Health Testing Center webpage)

 

Recommended Multiphasic Health Testing Center Application Form [110KB, DOCX]
Recommended Multiphasic Health Testing Center Application Checklist [50KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]

 

AHCA Form 3170-4001 [141KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX]

Nurse Registry
(Nurse Registry webpage)

 

Recommended Nurse Registry Application Form [94KB, DOCX]
Recommended Nurse Registry Application Checklist [55KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]

 

AHCA Form 3110-7004 [141KB, DOCX]
AHCA Form 3110-7004CL [55KB, DOCX]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX]
Nurse Registry Proof of Financial Ability to Operate [179KB, XLS]

Nursing Home
(Nursing Home webpage)

 

Recommended Nursing Home Application Form [118KB, DOCX]
Recommended Nursing Home Application Checklist [74KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]
Medicaid Lease Bond [9KB, PDF]
Unconditional Guarantee of Payment [10KB, PDF]
Gold Seal Application [63KB, DOCX]

 

AHCA Form 3110-6001 [399KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX]
Proof of Financial Ability to Operate [173KB, XLS]
Patient Trust Surety Bond [53KB, DOCX]

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

 

Recommended Organ Procurement / Tissue Bank / Eye Bank Application Form [91KB, DOCX]
Recommended Organ Procurement / Tissue Bank / Eye Bank Application Checklist [51KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]

 

AHCA Form 3140-2001 [122KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX]

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

 

Recommended Prescribed Pediatric Extended Care Centers Application Form[108KB, DOCX]
Recommended Prescribed Pediatric Extended Care Centers Application Form[113KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]

 

AHCA Form 3110-8002 [113KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX]
Proof of Financial Ability to Operate [361KB, XLS]

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

 

Recommended Residential Treatment Centers Application Form [113KB, DOCX]
Recommended Residential Treatment Centers Application Checklist [61KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]
HIV/AIDS Training Affidavit [22KB, PDF]
Community Residential Home Affidavit of Compliance [36KB, PDF]

 

AHCA Form 3180-5004 [302KB, DOC]
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 [101KB, DOCX]
Recommended Transitional Living Facilities Application Checklist [270KB, DOC]
Recommended Health Care Licensing Application Addendum [141KB, DOC]

 

AHCA Form 3110-9001 [270KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOC]

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