Facility Name Change Notice - Licensed Clinics
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 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, 1B, 2 & 10 of the application. Attach a copy of your current Health Care Clinic License.
APPLICATION AND INSTRUCTIONS - (AHCA Form 3110-0013 Revised)
