Reactivation after Expiration
For nonwaived laboratories only: If you received the Statement of Deficiencies
form (CMS 2567) in the mail with the certified letter regarding the expiration
of your license, complete and return your plan of correction on this form along
with the fee and forms required below.
Reactivation After Expiration Application
Required Clinical Laboratory Application Fees:
Laboratory application fees are dependent upon the type of laboartory and the volume of tests preformed
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.
Annual Affidavit of Background Screening Compliance
Each non - waived laboratory is required by section 435.04(05), Florida Statutes(2006) to submit an affidavit of compliance with this section. A recommended form is available at this the link below.
| 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. |
Separate forms are available for those responding to staff omission requestions. Note:The following forms and information are required if your laboratory license has expired and you wish to reactivate the license. Refer to item one for information. All applicants must complete the information in items 2 through 6. For laboratories performing waived testing and provider-performed microscopy (PPMP), also complete item 7.
- Laboratory Licensure Application Checklist
- Initial State Laboratory Licensure Application (AHCA FORM 3000-4) (140kb.pdf)
- Health Care Licensing Application
- Health Care Licensing Application Addendum
- Volunteer Board Member Affidavit
- Declaration of Proposed Test Menu (for completion by all applicants)
- Microscopy Evaluation Survey (complete if applying for "Provider-performed Microscopy" testing) (72kb.pdf)
- Self Evaluation Survey (complete if performing nonwaived testing other than only Provider-performed Microscopy)
- Affidavit of Compliance with Background Screening Requirements (Directors and Financial Officers of nonwaived laboratories must complete this form if background screening has been completed within the last five years.)
- Required State Application Fees
- How to Count Annual Test Volume (for non-waived applicants)
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