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Facility Name Change Notice - Licensed Clinics

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 (2009).

A license is valid only for the licensee, provider and location for which the license 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 change in facility name, select the link below and complete ONLY Sections 1A, 2, 3, 5, & 9 of the application. Attach a copy of your current Health Care Clinic License.

(No Fee Required)

APPLICATION AND INSTRUCTIONS

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Health Facility Regulation | Health Care Clinics | Important Notices & Alerts | HCC Statutes/Rules | Applications and Instructions | Medical/Clinic Director Info | Background Screening Info | Find a HCC Clinic