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Change of Address Notice - Certificate of Exemption
Fee $25

You must report a facility's change of location to the agency within 21 calendar days from the effective date of the change, as required by s. 408.810 (3), Florida Statutes.

A certificate of exemption is valid only for the licensee, provider and location for which the license is issued. A new certificate will not be issued for the new location until a change of address application is received and approved by the agency, or if the ownership and/or tax identification number(s) have changed.

To request a change of address, select the link below and complete ONLY Parts 1A, 1B, 2A and 6 of the application. Attach a copy of current Certificate of Exemption.

Fee – A $25 fee applies. Make check or money order payable to AHCA.  The agency does not accept starter checks.

APPLICATION AND INSTRUCTION (AHCA Form 3110-0014 September 2013) [MS Word 342KB]

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