Applications and Supporting Forms

 
 Form Number Name For Description

AHCA Form 3130-8001

Renew Online

Health Care Licensing Application Hospitals [160KB, DOC]

All application types Standard Hospital application required to apply for, renew or modify a Hospital license.
AHCA Form 3110-1024 Health Care Licensing Addendum [125KB, DOC]
Initial
Renewal
CHOW
Collects the confidential information to comply with the reporting requirements pursuant to Chapter 408, Part II, F.S.
AHCA Form 3130-8005 Comprehensive Emergency Management Planning Criteria for Hospitals [60KB, PDF] Initial
CHOW
Provides an outline to develop an emergency management plan. The plan must be approved by the county emergency operations center annually.
AHCA Form 3130-8012

Burn Unit Services Licensure Application [53KB, DOC]

Initial Designation Form to attest the hospital meets burn unit services criteria specified in 59A-3.2085(18), F.A.C. Attach to AHCA Form 3130-8001. Proof of Compliance with American Burn Association guidelines is required at license renewal.
AHCA Form 3130-5003

Adult Inpatient Diagnostic Cardiac Catheterization Licensure Application [55KB, DOC]

Initial Designation and
Licensure Renewal
Form attesting the Hospital will comply with rules that establish licensure standards for the provision of adult inpatient diagnostic cardiac catheterization services. Attach to AHCA Form 3130-8001.
AHCA Form 3130-8010 Level I Adult Cardiovascular Services [60KB, DOC]
Initial Designation and
Licensure Renewal
Form to attest adult cardiovascular services meet the criteria in 59A-3.2085(13), (16) and/or (17) F.A.C. Attach to AHCA Form 3130-8001.
AHCA Form 3130-8011 Level II Adult Cardiovascular Services [60KB, DOC]
Initial Designation and
Licensure Renewal
Form to attest adult cardiovascular services meet the criteria in 59A-3.2085(13), (16) and/or (17) F.A.C. Attach to AHCA Form 3130-8001.
AHCA Form 3130-8009
Stroke Center Affidavit [53KB, DOC]

Initial Designation Form to attest by affidavit the Hospital meets primary or comprehensive stroke center criteria as specified in 59A-3.2085(15), Florida Administrative Code (F.A.C.). Attach to AHCA Form 3130-8001.
 AHCA Form 3170-2004

Clinical Laboratory Applications

Initial
Renewal
CHOW
Miscellaneous

Clinical laboratory licenses under the same ownership/control as the Hospital (Hospital based) must concurrently submit a clinical laboratory application.
AHCA Form 3000-0001 Emergency Services Exemption Request Form [190KB, PDF]
Exemption Request Application required for Hospital emergency services exemption requests. Attach to AHCA Form 3130-8001.
  Certificate of Need Initial A written statement issued by the Agency evidencing community need for a new, converted, expanded, or otherwise significantly modified health care facility.
  Bed Memo

Initial
Any bed change

Internal AHCA memo signifying compliance with Florida Building Code and which lists the beds eligible for licensure.
  Business Articles Initial
CHOW
Articles of Incorporation or similarly titled document as filed with the Florida Department of State.
  Compliance with zoning requirements Initial
CHOW
Any documentation from a local government identifying the facility is in compliance with local zoning requirements.
  Certificate of Occupancy Initial Specific documentation from a local government granting the right to occupy a facility.
  Management Agreement Initial
CHOW
Contract between the owner and a management company for management services.
  Closing Document CHOW Bill of Sale or similar document signed by the buyer and the seller indicating the date of transfer of ownership.
  Statement of outstanding deficiencies CHOW Statement from the buyer assuring any uncorrected life-safety deficiencies will be corrected timely.
  Statement of outstanding payments CHOW Statement from the buyer identifying any outstanding balance owed AHCA, and indicating who will pay and when.
Top