BACKGROUND SCREENING ALERT |
| Applications and appropriate fees should be mailed to:
Laboratory Unit |
Multiphasic Health Testing Centers (MHTC)
Applications:
Complete the information in the forms below for an initial or renewal application. Instructions are included with each form.
- Initial or Renewal MHTC licensure application
- Health Care Licensing Applicaton
- Health Care Licensing Application Addendum
- Voluntary Board Member Affidavit
- Affidavit of Compliance with Background Screening Requirements
New Requirements Effective 7/1/2009:
- Voluntary Board Member Affidavits are no longer required (see page 67 in changes in law)
- The Laboratory Director, Chief Financial Officer and controlling interest as defined under section 409.803 (7), Florida Statutes, must submit social security numbers. Forms are currently being revised, but until they can be revised, please submit on a separate piece of paper. [see section 408.806(1)(a), Florida Statutes]
- Affidavit for background screening for covered employees may be submitted with the application rather than annually. Annual Background Screening Affidavit
- Renewal applications submitted more than 120 before the expiration date must be returned to the applicant and cannot be accepted by the Agency
Background Screening:
Level 2 Background Screening must be completed for the laboratory director and the chief financial officer prior to approving the initial application and then repeated every five years. Please go to the background screening section of this web site for additional documentation that must be submitted with your application. Fingerprint cards are available by contacting the Laboratory Unit at 850-487-3109. Other fingerprint cards may not be acceptable.
Director’s Qualifications
Director qualifications must be submitted for all physician and non - physician laboratory directors.
The State of Florida requirements for laboratory directors can be found at the
Florida Administrative Code (See Chapter 59A-7 for Clinical Laboratory Rules) website:
http://www.flrules.org/gateway/ChapterHome.asp?Chapter=59A-7
CLIA requirements for directors of moderate complexity testing are at the following link: http://www.phppo.cdc.gov/clia/regs/subpart_m.aspx#493.1405,
CLIA requirements for directors of high complexity testing the requirements are at this link: http://www.phppo.cdc.gov/clia/regs/subpart_m.aspx#493.1443.
| NOTE: If after reviewing the application forms and statutory and rule requirements on our website you have additional questions, please call (850) 487-3109. Staff will be happy to answer questions that clarify the requirements as they apply to your specific situation, but cannot walk you through the application. Filling out the application is part of your responsibility as an applicant. The Agency's role in this process is to evaluate your application and, if there are elements missing from your application once submitted, provide you with an omissions response that gives you another opportunity to complete the application successfully. If you need extensive assistance in filling out your application, we would advise you to retain an attorney or a government relations consultant to assist you. |
