Facility Name Change Notice - Certificate of Exemption
Fee $25 (New)
You must report a facility's name change 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 certificate is issued. A facility name change application will be accepted only when the corporate and/or fictitious name(s) have been changed. A facility name change application will not be accepted if the ownership and/or tax identification number(s) have changed.
To request a facility name change, select the link below and complete Parts 1A, 1B, 2A and 6 of the application, only. Attach a copy of current Certificate of Exemption.
APPLICATION AND INSTRUCTIONS (AHCA Form 3110-0014)
