Ambulatory Surgical Center
An ambulatory surgery center (ASC) is a licensed facility that is not part of a hospital and that may also be Medicaid/Medicare certified. The primary purpose of this type of facility is to provide elective surgical care. The patient is admitted to and discharged from the facility within the same working day. Overnight stays are not permitted.
Initial License Requirements
Initial applicants must contact the Agency’s Office of Plans and Construction (850) 487-0713 for compliance with appropriate building code before applying for licensure. Applications and supporting forms listed below must be submitted at least 60 days but no more than 120 days prior to the anticipated opening date. The license fee is $1,542.00 and the survey/inspection fee is $400.00. Applications submitted without the appropriate fees will not be accepted.
Required documentation/forms
- Ambulatory Surgical Center Licensure Application (171 KB .doc)
- Health Care Licensing Application, Addendum , Voluntary Board Member Affidavit. . These forms are recommended for use beginning October 1, 2006, to comply with the reporting requirements pursuant to Chapter 408, Part II, Florida Statutes. Please provide this information in addition to the licensing application for the specific provider/facility type.
- Compliance with the background screening requirements. See the background screening section below for the required annual attestation form and additional information. Fingerprint cards may be requested by calling (850) 487-2717. The Affidavit of Compliance with Background Screening Requirements may be used to document compliance if an appropriate screen was conducted within the past 5 years through another state agency.
- Affidavit of compliance with fictitious name registration
- Articles of incorporation in Florida
- Zoning certification or proof of compliance with zoning requirements
- Approval of the physical plant from the Agency for Health Care Administration,
Office of Plans and Construction
- $1942.00 Initial Licensure and Survey Fee.
Change of Ownership Licensure Requirements
A licensure application, supporting forms and information listed below must be submitted at least 60 days prior to the change of ownership. The change of ownership application fee is $1,542.00. Documentation signed by the buyer and seller that will substantiate the change of ownership has occurred must be submitted before the application can be approved.
Required documentation/forms
- Ambulatory Surgical Center Licensure Application (171 KB .doc)
- Health Care Licensing Application, Addendum , Voluntary Board Member Affidavit. . These forms are recommended for use beginning October 1, 2006, to comply with the reporting requirements pursuant to Chapter 408, Part II, Florida Statutes. Please provide this information in addition to the licensing application for the specific provider/facility type.
- Compliance with the background screening requirements. See the background screening section below for the required annual attestation form and additional information. Fingerprint cards may be requested by calling (850) 487-2717. The Affidavit of Compliance with Background Screening Requirements may be used to document compliance if an appropriate screen was conducted within the past 5 years through another state agency.
- Anticipated date of the transfer of ownership.
- Affidavit of compliance with fictitious name registration.
- Articles of incorporation in Florida.
- Zoning certification or proof of compliance with zoning requirements.
- Affidavit from the buyer that any deficiencies identifed on the most recent
Life Safety Code inspection will be corrected.
- Affidavit from the buyer and seller that any outstanding fees owed the State will be paid, identifying who will pay and when it will be paid.
- Proof of transfer of ownership signed by both the buyer and the seller.
- $1,542.00 change of ownership licensure fee.
Renewal Requirements
A licensure application and the supporting forms listed below must be submitted at least 60 days prior to the current license expiration date. A late fee of $50.00 per day, up to a maximum of $500.00 will apply to any application received less than 60 days prior to expiration. A renewal application will not be accepted if the ambulatory surgical center license is expired. Expired licenses may be reactivated by applying as an initial applicant as outlined above. The renewal application fee is $1,542.00.
Required documentation/forms
Medicare Certification Requirements
Medicare certification for initial enrollment or change of ownership is achieved by adherence to requirements in 42
Code of Federal Regulations, Part 416. This includes submission of the following to the Agency for Health Care Administration, Hospital and Outpatient Services Unit:
Fiscal Intermediary Choice
Form
Accreditation Attestation
Statement (433K PDF)
Health Insurance Benefits Agreement
-- 2 copies required (Form CMS 370)
Request for certification in
Medicare/Medicaid program (Form CMS 377)
Assurance of Compliance
(Form HHS 690)
In addition, a CMS Form 855B must be submitted to their Fiscal Intermediary/Carrier.
Accredited Ambulatory Surgical Centers
Ambulatory Surgical Centers accredited by JCAHO or AAAHC are exempt from annual licensing surveys as indicated in section 59A-5.004(2), F.A.C. License validation surveys are conducted each year by AHCA on a minimum of five percent of the facilities that have received accreditation. These surveys are completed within 60 days of the accreditation organization's survey date. For Additional information on accreditation contact the accrediting organization linked below.
Joint Commission on Accreditation of Health Care Facilities (JCAHO)
Accreditation Association for Ambulatory Health Care, Inc (AAAHC)
Background Screening
Florida Department of Law Enforcement and FBI fingerprinting must be completed by the administrator/chief executive officer and repeated every five years unless there is a new hire. Please go to the background screening section of this web site for additional documentation that must be submitted with your application.
Statute/Rule Authority
Forms
Updated June 27, 2008
|
