Hospitals
Laura MacLafferty, Unit Manager |
A hospital offers services more intensive than those required for room, board, personal services and general nursing care, and offers facilities and beds for use beyond 24 hours by individuals requiring medical, surgical, psychiatric, testing, diagnosis, treatment, or care for illness, injury, deformity, infirmity, abnormality, disease, or pregnancy. Also available are clinical laboratory services, diagnostic X-ray services, and treatment facilities for surgery, obstetrical care, or other definitive medical treatment of similar extent.
A license issued by the Agency for Health Care Administration is required in order to operate a hospital. It is unlawful for a person to use or advertise to the public, in any way or by any medium whatsoever, any facility as a "hospital" unless such facility has first secured a license under the provisions of Chapter 395, Part I, Florida Statutes and Chapter 408, Part II, Florida Statutes. This licensure does not apply to veterinary hospitals or to commercial business establishments using the word "hospital" as a part of a trade name if no treatment of human beings is performed on the premises of such establishments.
Hospitals must maintain current state licensure, but may choose to be Medicare certified and may chose to be accredited by The Joint Commission, American Osteopathic Association's Healthcare Facilities Accreditation Program or Det Norske Veritas. Accredited hospitals meeting Chapter 59A-3.253(3), Florida Administrative Code are "deemed" to be in compliance with the licensure and certification requirements and do not receive routine on-site surveys. All hospitals are subject to periodic Life-Safety Code inspections.
Copies of licenses, applications and other documents issued by or submitted to the Agency are public record, but are not posted on this page. If you are searching for public records, please check the following sources:
| Inspection reports | Locate a facility/license | Request public records | Risk management reporting |
If you cannot find what you are looking for on this page, please contact the Hospital and Outpatient Service Unit by calling (850) 487-2717. Links to certain topics are listed below. Click on the topic to jump to that section. This page contains general instructions, applications, forms and links to applicable regulations in order to obtain and maintain a Florida hospital license. In addition, lists of frequesntly requested hospital services are also included here.
Licensure Requirements
Initial
This includes new facilities and reactivation of an expired license. Hospitals require a Certificate of Need, so the first step to licensure is to notify the Certificate of Need/Financial Analysis Unit and make an application for project review. Once a Certificate of Need is issued but prior to beginning new construction or remodeling an existing building, applicants must contact the Agency's Office of Plans and Construction for a plan review. At least 60 days before building completion and anticipated utilization, an applicant must submit a licensure application, fees and supporting documents. When all required information is received and acceptable, a licensure survey will be scheduled. A license will be issued when documentation of a successful licensure survey is complete and filed. Please note a valid license is required before patient care can be provided. A separate application is required for each facility located on separate premises that are listed on a single license.
Renewal
To renew a current state license, the licensure application, renewal fee and supporting documents must be submitted to the Agency 120 to 60 days prior to the expiration date. A late fee of $50 per day, up to $500 will be assessed for any application not received 60 days prior to expiration. NOTE: A renewal application will not be accepted if the hospital license is expired. An initial license application must be filed if the license has expired. A separate application is required for each facility located on separate premises that are listed on a single license.
Change of Ownership (CHOW)
Chapter 408.803, Florida Statutes defines "Change of ownership" as: an event in which 51 percent or more of the ownership, shares, membership, or controlling interest of a licesee is in any manner transferred or otherwise assigned. this does not apply to a licensee that is publicly traded on a recognized stock exchange. Also, a change solely in the management company or board of directors is not a change of ownership.
The licensure application, fee and supporting forms must be submitted at least 60 days prior to the date of acquisition of the hospital. Before the application can be approved, a bill of sale or other closing document signed by the buyer and the seller and showing the effective date of the transfer must be received by the Agency. A separate application is required for each facility located on separate premises that are listed on a single license.
Other Change During the Licensure Period
Additions, deletions or other changes to licensed beds, off-site outpatient facilities, off-site emergency departments and name and address changes, including relocations and replacement facilities, require an AHCA Form 3130-8001, Hospital licensure application. Other documents that may be required include AHCA Form 3130-8008, AHCA Form 3130-8003, and select background screening documentation depending on the effect of the changes to other services and regulatory requirements.
Voluntary Termination of a License
A licensee must inform the agency not less than 30 days prior to the discontinuance of operation and comply with the requirements listed in Chapter 408.810(4), Florida Statutes.
Applications and Supporting Forms
For Initial, Renewal, CHOW, and changes during the licensure period. Applications and forms for specific programs such as Stroke Center designation and Level I or Level II Adult Cardiovascular Services are located in their respective sections on this page.
Form Number |
Name |
For |
Description |
|---|---|---|---|
| AHCA Form 3130-8001 | Hospital licensure application (198K doc) | All application types |
Standard hospital application required to apply for or modify a hospital license. |
| Recommended Form | Health Care Licensing Application | Initial Renewal CHOW |
Please provide this information to comply with the reporting requirements pursuant to Chapter 408, Part II, Florida Statutes. Use of the form is not required if the same information is provided by other means. |
| Recommended Form | Health Care Licensing Addendum | Initial Renewal CHOW |
Please provide this information to comply with the reporting requirements pursuant to Chapter 408, Part II, Florida Statutes. Use of the form is not required if the same information is provided by other means. |
| AHCA Form 3130-8008 | Emergency Services Form (28K PDF) | Initial Renewal CHOW Any application resulting in a change to the list of emergency services offered . |
Mark the appropriate box for each service listed. |
| AHCA Form 3130-8003 | Patient's Compensation Form (361K) | Initial Renewal CHOW licensed bed increase |
Must be submitted at least annually to document compliance with §766.105, Florida Statutes: at license renewal and insurance policy renewal |
| AHCA Form 3130-8005 | Comprehensive Emergency Management Planning Criteria for Hospitals | 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 3100-0007 | Annual Affidavit of Compliance with Level 2 Background Screen for Covered Employees | Initial Renewal CHOW |
Must be submitted annually. |
| AHCA Form 3100-0008 | Affidavit of Compliance with Level 2 Background Screen Requirements | Initial Renewal CHOW (if applicable) |
Use this form to document a current level 2 background screen performed via another state agency in lieu of submitting a fingerprint card and fee to AHCA. Screen results must be attached. |
| Accred | Accreditation Attestation Statement | Renewal CHOW |
Allows the accreditation organization to release information to the Agency. May be used to document continuing accreditation while the full accreditation report is pending. |
| 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. |
Licensure Fees
Fee Type |
How Much |
Who Pays |
When |
| Initial, renewal or CHOW Application | $31 per licensed bed or $1,542, whichever is more. | Initial, Renewal and CHOW applicants | With application |
| Other Change During the Licensure Period | $31 per new licensed bed. No charge for removing beds from a license or changing the utilization. | Bed addition applicants |
With application |
| Licensure survey | $12 per licensed bed or $400, whichever is more. | Initial applicants All unaccredited hospitals and accredited hospitals selected for a validation survey |
Initial applicants submit payment with the application. Licensed hospitals will be billed in advance. |
| Life-safety survey | $1.50 per licensed bed or $40, whichever is more. | All licensed hospitals | Licensed hospitals will be billed in advance. |
| Background Screen | $43.25 per screen for Level 2 |
CEO and CFO must be screened. A screen is valid for 5 years. | When a fingerprint card is submitted for processing. |
Late application |
$50 per day, up to $500 | All late applicants | If an application is not received at least 60 days prior tothe anticipated effective date. Payment can be made any time during the application process or upon issuance of a final order. |
State and Federal Regulations
- Chapter 395, Part 1, Florida Statutes
- Chapter 59A-3, Florida Administrative Code
- Chapter 408, Part II, Florida Statutes
- Search all of Title 42 Code of Federal Regulations (CFR)
- Title 42 Chapter IV, Parts 430 to End
- Title 42 Chapter IV, Part 412, Prospective Payment Systems for Inpatient Hospital Services
Medicare Certification Requirements
To meet federal requirements, the hospital must be surveyed for certification as directed by the Centers for Medicare and Medicaid Services. A facility seeking initial licensure and certification will receive two (2) surveys; one licensure survey before operation begins followed by a certification survey after the facility is fully operational. Psychiatric facilities require an additional certification of the two (2) Medicare special conditions of participation.
Participation in the Medicare/Medicaid program(s) will depend upon an effective date recommended by the Agency for Health Care Administration. Federal regulations permit this date to be the date of initial certification if all federal requirements are met. If all requirements are not met, the effective date is the date requirements are met or the date you submit an acceptable plan of correction or waiver request.
Form |
Description |
|---|---|
| Medicare Administrative Contractor Choice Form | Identifies the facility's intermediary and cost reporting fiscal year end. |
| Health Insurance Benefit Agreement Form (Form CMS --1561) | Two original forms are required. Do not photocopy. |
| Hospital/CAH Database worksheet | Information will be collected on-site if a survey is required. For a change of ownership, it must be supplied to the licensure unit. |
| Medicare Certification Civil Rights Information Request Form - OMB 0990-0243 | Checklist of required information. Two original HHS 690 forms and appropriate facility brochures must be attached. |
| Assurance of Compliance (Form HHS -- 690) | Required form to be submitted in duplicate with the above civil rights form. |
| Certification of Civil Rights Compliance Requirements | Technical assistance provided by the Office of Civil Rights. This information includes examples of the information to be submitted with the above Medicare Certification Civil Rights Information Request Form. |
Hospital Emergency Access
Any person needing emergency medical care or any woman in active labor shall not be denied access to appropriate emergency medical services and care.
Emergency services and care means medical screening, examination and evaluation by a physician, or by other appropriate personnel under the supervision of a physician, to determine if an emergency medical condition exists.
Emergency Services Inventory
The inventory chart linked below lists hospitals alphabetically by county and indicates types of emergency services available at the facility. Also, please note that some facilities have been granted an exemption or a partial exemption from the requirement of providing certain services on a 24 hour basis seven days a week. Those facilities are indicated by a "X1" with a red background. Details of the exemption are included in the separate document "Emergency Services Exemptions" below. Emergency services reported to the Agency are listed on the face of the hospital's license.
DOH Trauma Center Designation
As part of the emergency services inventory, hospitals indicate if they have met trauma center criteria. The Department of Health has the responsibility for the planning, and establishment of a statewide trauma system so all applications and inquiries must be sent to the Department of Health's Office of Trauma. Applications, statute and rule references and a list of current certified trauma centers and contact information is available on their web site.
Off-site Emergency Departments
Any Florida licensed hospital which has a dedicated emergency department may provide emergency services in a location off of the hospital's main premises. The off-site emergency department must be under the same direction, offer the same services and comply with the same regulatory requirements as the emergency department located on the hospital's main premises. There are no additional rules or standards specific for emergency departments located off the premises of the licensed hospital.
Hospitals desiring to offer off-site emergency departments must meet the physical plant requirements of s. 395.0163, F.S. The Agency must review the facility' plans and specifications before any construction can begin. Reviews are also conducted during the construction phase and final physical plant approval is granted when the facility is determined to meet all applicable hospital building code. Off-site emergency departments must meet the occupancy and construction requirements of the Life Safety Code and Florida Building Code relevant to the actual use of the facility. The off-site emergency department must meet all of the physical plant requirements of an onsite emergency department as described in s. 419.4.11 of the Florida Building Code and also meet the requirements of s. 7.D.9, Definitive Emergency Care (Guidelines for the Design and Construction of Hospitals and Health Care Facilities, 2001) incorporated by referenced in s. 419.2.1.2 of the Florida Building Code.
Application to add an off-site emergency department must be made on AHCA Form 3130-8001 with documentation providing proof of ownership or right to occupy the premises and revised services provided, if applicable. Application should be made for other change during the licensure period.
A moratorium on approving off-site emergency departments was initiated in 2004 and continued until June 30, 2006.
- List of Florida Licensed Hospitals with Off-site Emergency Departments
- Report on Freestanding Emergency Departments
- Emergency Department Utilization Report
AHCA Emergency Status System (ESS)
The AHCA Emergency Status System (ESS) is a web-based application designed to track the status of 24-hour care providers regulated by AHCA. The system allows direct data entry by provider staff that have an active user agreement with AHCA. Data entry may include details of impacts and damages, evacuation status, available beds, special medical client needs, and names and phone numbers of emergency contacts.
ESS data is organized around Events. Events are specific emergencies (hurricane) or activities (Superbowl) that require tracking of information. For example, a hurricane would be an event and would be given a name consistent with a storm such as "Jeanne". This enables all activities (evacuation, impact and needs) to be associated with a specific event and when an event is complete or closed, those activities are archived with that event.
ESS is always available but some information can only be entered when an event is open. Emergency contact information and generator information can be entered at any time.
The ESS web address is http://ess.myflorida.com.
State of Florida Emergency Medical Services Plan
Pursuant to sections 395.103 and 401.015, F.S., hospitals with an emergency department must have an onsite telecommunications device that meet the requirements of the EMS Communications Plan. Additional information regarding compliance with the requirements or obtaining assistance in meeting those requirements is contained in the following memo:
State Emergency Services Assessment Form
Hurricane/Disaster Preparedness
PPS Hurricane Waiver
The Centers for Medicare Medicaid Services (CMS) has announced a data submission waiver for Prospective Payment System hospitals for the second, third, and fourth quarters of 2005 for hospitals impacted by hurricanes in the listed Florida counties.
Transplant Centers
Hospitals providing organ transplant services must meet state and federal requirements. The federal requirements and a nationwide list of providers are available on the Centers for Medicare and Medicaid Services web page.
Chapter 408.036(1)(k), Florida Statutes require hospitals to obtain a Certificate of Need for the establishment of organ transplantation programs.
Background Screening
Select hospital personnel must undergo a level 2 background screening pursuant to Chapter 435, Florida Statues. A level 2 screening consists of:
- Federal Bureau of Investigation (FBI)
- Florida Department of Law Enforcement (FDLE)
Screening is required for the chief executive officer or similarly titled individual who is responsible for the day-to-day operations of the applicant, and the chief financial officer or similarly titled individual who is responsible for the financial operation of the applicant. Also, for each officer, board member, partner or person owning 5% or more who has been convicted of an offense prohibited by section 435.04, F.S., the facility shall submit to the Agency, a description and explanation of the conviction at the time of the license application.
Applicants for relicensure will need to submit proof that the appropriate individuals have satisfactorily completed the required screening within the last 5 years. If this screening has been completed for another type of Florida license, the Agency may be able to use those screening results, if the proof of screening provides all information needed. Submit a copy of your screening results from the Department of Health, Agency for Persons with Disabilities, Department of Children and Families, or Department of Financial Services together with your Affidavit of Compliance. Please be aware that background screens offered via the internet are not equivalent to the screen required by section 435, F.S.
If the required screening has not been completed and the Agency is to conduct the screening at the time the application is processed, please call (850) 487-2717 now and ask that FBI fingerprinting cards be mailed to you. When you submit your application to the Agency, you should include the completed fingerprint cards and a check or money order to pay for the background screening costs.
The cost for a level II Request (FDLE screening and FBI fingerprinting) is $43.25 per screen.
Primary Stroke Center & Comprehensive Strokes Center Designation
As specified in s 395.3038, Florida Statutes, the Agency has adopted administrative rules that
provide criteria for designation of hospital programs as primary stroke centers and comprehensive stroke centers. This statutory
section requires that the criteria be substantially similar to the criteria for stroke center certification established by the Joint Commission (formerly known as the Joint Commission on Accreditation of Healthcare Organizations).
Agency administrative rules in 59A-3.2085(15), Florida Administrative Code (F.A.C.), which became final on March 23, 2006, have incorporated Joint Commission criteria for primary stroke centers. Criteria for comprehensive stroke centers included in these rules are adopted from the criteria developed by the Brain Attack Coalition since Joint Commission has not yet established comprehensive center criteria.
Stroke centers providing the required affidavit and documentation will be included on the listing of stroke centers maintained by the Agency. This listing will be updated as additional hospitals provide required documentation. This listing will be included on this website and provided to the Department of Health Bureau of Emergency Services.
Designated Stroke Centers
Centers are included in these listings on the basis of the hospital providing an affidavit and necessary documentation attesting that the stroke center meets the criteria in 59A-3.2085(15), F.A.C., for a primary or comprehensive stroke center.
Listing of stroke centers may be viewed using the following link:
The requirement to provide services and care specified in section 395.1041, Florida Statutes, or the Emergency Medical Treatment and Active Labor Act (EMTALA) is not affected by the creation of this listing of stroke treatment centers or the adoption of administrative rule criteria for those centers. Hospital Emergency Departments continue to be required to provide emergency treatment to persons presenting to those departments. The creation of a listing of Stroke Treatment Centers does not constitute the basis for refusing services or declining to provide emergency services and stabilizing an individual presenting to an emergency department.
Stroke Center Rules, Criteria, and Forms
Level I and Level II Adult Cardiovascular Services Designation
As specified in s. 408.0361, Florida Statutes, the Agency has adopted administrative rules that provide criteria for designation of hospital programs as a Level I program authorizing the performance of adult percutaneous cardiac intervention without onsite cardiac surgery and a Level II program authorizing the performance of percutaneous cardiac intervention with onsite cardiac surgery. This statutory section requires that such programs comply with the most recent guidelines of the American College of Cardiology and American Heart Association guidelines for staffing, physician training and experience, operating procedures, equipment, physical plant, and patient selection criteria to ensure patient quality and safety.
Agency administrative rules in 59A-3.2085(13), (16), (17), and (18) Florida Administrative Code (F.A.C.), which became final on January 8, 2009, have incorporated by reference the following guidelines:
Hospitals providing the required attestation will have the appropriate Level I or Level II designation added to the hospital license for the current licensure period. Existing Level I and Level II adult cardiovascular services programs must renew their licenses at the time of the hospital license renewal by submitting an updated attestation.
A listing of current hospitals providing Adult Cardiovascular Services will be maintained by the Agency. This listing will be updated as additional hospitals provide required documentation and will be included on this website.
Designated Adult Cardiovascular Services Hospitals
Hospitals are included in these listings on the basis of providing an attestation that the Adult Cardiovascular Services meet the criteria in 59A-3.2085(13), (16) and/or (17) F.A.C.
Adult Cardiovascular Services Rule and Criteria
Adult Cardiovascular Services License Applications
- License Application Level I Adult Cardiovascular Services Attestation, AHCA Form 3130-8010
- License Application Level II Adult Cardiovascular Services Attestation, AHCA Form 3130-8011
- License Application Adult Inpatient Diagnostic Cardiac Catheterizaion, AHCA Form 3130-5003
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Other Report Forms
- Fire Incident Report Form (344K PDF)
- AHCA Form 3130-8006, Organ & Tissue Donation Request Summary Data Form
Notification of Disposition of Fetal Remains Form (AHCA Form 3100-0006 January 2005)
Reporting Death in Restraint/Seclusion to CMS
The Code of Federal Regulation, Part 42, section 482.13(g) Patients' Rights Final Rule, published December 8, 2006 and effectuated by CMS January 8, 2007, states, Hospital must report the following information to CMS:
- Each death that occurs while a patient is in restraint or seclusion.
- Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion.
- Each death known to the hospital that occurs within one week after restraint or seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to the patient's death. For the purpose of this regulation "reasonable to assume" includes, but is not limited to, deaths related to restrictions of movement for prolonged periods of time, or death related to chest compression, restriction of breathing, or asphyxiation.
Each death must be reported to CMS by telephone no later than the close of business the next business day following knowledge of the patient's death.
Hospital staff must document in the patient's medical record the date and time the death was reported to CMS.
- Hospital Restraint/Seclusion Death Report Worksheet (495kb.pdf)
- Email Instruction (495kb.pdf)
Mandatory Monthly Report of Induced Terminations of Pregnancy (ITOP)
Chapter 390.0112, Florida Statutes, requires each director of any medical facility to submit a monthly report of induced terminations of pregnancy to the Agency. The report must be submitted within 30 days following the preceding month and a $200 fine may be imposed if reports are not submitted timely. The statute requires that data reported shall be kept confidential. The reports are not permitted to be released to anyone except upon court order in a civil or criminal proceeding.
Effective July 13, 2008, the monthly report must be submitted electronically to the Agency.
ITOP Provider Enrollment User Agreement and Instructions
ITOP Monthly Reporting Web-Based System
Updated February 2, 2010
