Health Care Clinic Licensing Application [151KB, DOC]
Medical/Clinic Director Attestation Form [30KB, DOC]
Health Care Licensing Application Addendum [127KB, DOC]
Proof of Financial Ability to Operate Form [361KB, XLS]
Attestation of Compliance with Background Screening Requirements [430KB, PDF] - Refer to Rule 59A-35A.090 (2)(3), F.A.C.
Initial or Change of Ownership applications only - Any proof of financial ability to operate documents submitted to the Agency fall under the “Sunshine” law and would be available for public inspection, if requested. The only items that would not be available would be items that are exempt from public inspection, which include personal health care information protected under HIPAA and account numbers on items like bank statements. Public records are governed by Chapter 119, Florida Statutes. The Agency does not have the authority to grant a public records exemption.
Initial, Renewal, or Change of Ownership License Applications: Applicants and controlling interests [owners of at least 5% of the business entity, sole proprietors and partners] who are nonimmigrant aliens, as described in Title 8 U.S.C. s. 1101 (a) (15) must file a surety bond of at least $500,000, payable to the agency, which guarantees that the health care clinic will act in full conformity with all legal requirements for operation. A $500,000 bond must be obtained in compliance with s. 408.8065 (2), Florida Statutes.