Abortion Clinic
(Abortion Clinic webpage) |
Recommended Abortion Clinic Application Form [111KB, DOCX]
Recommended Abortion Clinic Application Checklist [51KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]
|
AHCA Form 3130-1000 [111KB, DOC]
AHCA Form 3130-1000CL [53KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [178KB, DOCX]
Abortion Clinic Incident Reporting Form [74KB, DOCX]
Refusal to Permit Administration of Rho(D) Immune Globulin Form [49KB, DOCX] |
Adult Day Care Center
(Adult Day Care Center webpage) |
Recommended Adult Day Care Center Application Form [104KB, DOCX]
Recommended Adult Day Care Center Application Checklist [64KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]
Proof of Financial Ability to Operate [431KB, XLS]
Specialty License Notification Form [75KB, DOC]
Specialty License Affidavit of Compliance [150KB, PDF]
ADCC Operator Identification [58KB, PDF] |
AHCA Form 3180-1004 [321KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX]
AHCA Form 3100-0009 [361KB, XLS] |
Adult Family Care Home
(Adult Family Care Home webpage) |
Recommended Adult Family Care Home Application Form [242KB, DOC]
Recommended Adult Family Care Home Application Checklist [60KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]
Income and Expense Statement [34KB, PDF]
AFCH Local Zoning Form [37KB, PDF]
|
AHCA Form 3180-1022 [195KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX] |
Ambulatory Surgical Center
(Ambulatory Surgical Center webpage) |
Ambulatory Surgical Center Application Checklist [51KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]
|
Ambulatory Surgical Center Licensure Application, ACHA Form 3130-2001 [109KB, DOCX]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX]
AHCA Form 3500-0011 [49KB, DOCX |
Assisted Living Facility
(Assisted Living Facility webpage) |
Recommended Assisted Living Facility Application Form
[450KB, DOCX]
Recommended Assisted Living Facility Application Checklist [121KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]
Proof of Financial Ability to Operate for ALFs with 16 or Less Beds [240KB, XLS]
Proof of Financial Ability to Operate for ALFs with 17 or More Beds [408KB, XLS] |
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX]
ALF Notification of Change of Administrator [86KB, DOC]
|
Birth Center
(Birth Center webpage) |
Birth Center Application Checklist [52KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC] |
Birth Center Licensure Application, AHCA Form 3130-3001 [103KB, DOCX]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX] |
Clinical Laboratory
(Non-Waived Lab webpage) |
CLIA Application Form CMS-116 PDF [ PDF] |
Drug Free Workplace Laboratory
(Drug Free Workplace Laboratory webpage) |
Recommended Drug Free Workplace Lab Application Form [119KB, DOCX]
Recommended Drug Free Workplace Lab Application Checklist [50KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]
|
AHCA Form 3170-5001 [169KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [169KB, DOCX] |
Health Care Clinic
(Health Care Clinic webpage) |
Recommended Health Care Clinic Licensure Application Form [120KB, DOC]
Recommended Health Care Clinic Licensure Application Checklist [46KB, DOC]
Recommended Health Care Licensing Application Addendum [141KB, DOC]
|
AHCA Form 3110-0013 [150KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [169KB, DOCX]
Medical Clinic Director Attestation [33KB, DOCX]
Proof of Financial Ability to Operate [361KB, XLS]
|
Health Care Clinic Exemption from Licensure
(Health Care Clinic Exemption webpage) |
Health Care Clinic Exemption Application Checklist [50KB, DOCX]
|
Health Care Clinic Exemption from Licensure Application, AHCA Form 3110-0014 [80KB, DOCX] |
Health Care Services Pool
(Health Care Services Pool webpage) |
Recommended Health Care Services Pool Application Form [306KB, DOCX]
Recommended Health Care Services Pool Application Checklist [50KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]
|
AHCA Form 3110-1010 [263KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX] |
Home Health Agency
(Home Health Agency webpage) |
Recommended Home Health Agency Application Form [114KB, DOCX]
Recommended Home Health Agency Application Checklist [60KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]
|
AHCA Form 3110-1011 [124KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX]
Attestation of Compliance with Distance Requirements [46KB, DOCX]
Proof of Financial Ability to Operate [361KB, XLS] |
Home Health Agency Exemption from Licensure
(Home Health Agency webpage) |
Recommended Home Health Agency Exemption Application Form [89KB, DOCX]
Recommended Home Health Agency Exemption Application Checklist [50KB, DOCX]
|
Home Medical Equipment Provider
(Home Medical Equipment Provider webpage) |
Recommended Home Medical Equipment Application Form [552KB, DOCX]
Recommended Home Medical Equipment Application Checklist [71KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC] |
AHCA Form 3110-1005 [501KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX]
AHCA Form 3110-1020, Request for Change of Name and/or Address [56KB, DOC]
Proof of Financial Ability to Operate [361KB, XLS] |
Home for Special Services
(Home for Special Services webpage) |
Recommended Home For Special Services Application Form [262KB, DOC]
Recommended Home For Special Services Application Checklist [96KB, DOC]
Recommended Health Care Licensing Application Addendum [141KB, DOC]
|
AHCA Form 3110-3001 [262KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX] |
Homemaker & Companion Services Provider
(Homemaker & Companion Services Provider webpage) |
Recommended Homemaker & Companion Services Provider Application Form [107KB, DOCX]
Recommended Homemaker & Companion Services Provider Application Checklist [69KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]
|
AHCA Form 3110-1003 [109KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX] |
Hospice
(Hospice webpage) |
Recommended Hospice Application Form [127KB, DOCX]
Recommended Hospice Application Checklist [65KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC] |
AHCA Form 3110-4001 [166KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX]
Proof of Financial Ability to Operate [361KB, XLS]
Attestation of Compliance with Applicable Life Safety Codes for Additions to Existing Hospice Inpatient Facilities/Residential Units [59KB, DOC] |
Hospital
(Hospital webpage) |
Recommended Hospital Application Form [122KB, DOCX]
Recommended Hospital Application Checklist [55KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]
Recommended Licensing Application Alternate-Site Testing, AHCA Form 3130-8013 [60KB, DOC]
|
AHCA Form 3130-8001 [160KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX]
AHCA Form 3500-0011 [49KB, DOCX]
Emergency Services Exemption Request Form [141KB, PDF]
Burn Unit Services Application [109KB, DOC]
Adult Inpatient Diagnostic Cardiac Catheterization Application[108KB, DOC]
Level I Adult Cardiovascular Services Application [116KB, DOC]
Level II Adult Cardiovascular Services Application [116KB, DOC] |
Intermediate Care Facility for the Developmentally Disabled
(Intermediate Care Facility for the Developmentally Disabled webpage) |
Recommended IFC/DD Application Form [109KB, DOC]
Recommended IFC/DD Application Checklist [68KB, DOC]
Recommended Health Care Licensing Application Addendum [141KB, DOC]
|
AHCA Form 3110-5003 [333KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX]
AHCA Form 3500-0011 [49KB, DOCX]
Proof of Financial Ability to Operate [173KB, XLS]
|
Mental Health Services -
(CSU / SRT webpage)
(RTF webpage) |
Recommended CSU/SRT Application Form [114KB, DOCX]
Recommended CSU/SRT Application Checklist [61KB, DOCX]
Recommended RTF Application Form [110KB, DOCX]
Recommended RTF Application Checklist [62KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]
HIV/AIDS Training Affidavit [22KB, PDF]
Local Zoning Form (Levels I-A, I-B, and II) [32KB, PDF] |
AHCA Form 3180-5003 [319KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOC] |
Multiphasic Health Testing Center
(Multiphasic Health Testing Center webpage) |
Recommended Multiphasic Health Testing Center Application Form [110KB, DOCX]
Recommended Multiphasic Health Testing Center Application Checklist [50KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC] |
AHCA Form 3170-4001 [141KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX] |
Nurse Registry
(Nurse Registry webpage) |
Recommended Nurse Registry Application Form [94KB, DOCX]
Recommended Nurse Registry Application Checklist [55KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]
|
AHCA Form 3110-7004 [141KB, DOCX]
AHCA Form 3110-7004CL [55KB, DOCX]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX]
Nurse Registry Proof of Financial Ability to Operate [179KB, XLS] |
Nursing Home
(Nursing Home webpage) |
Recommended Nursing Home Application Form [118KB, DOCX]
Recommended Nursing Home Application Checklist [74KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]
Medicaid Lease Bond [9KB, PDF]
Unconditional Guarantee of Payment [10KB, PDF]
Gold Seal Application [63KB, DOCX] |
AHCA Form 3110-6001 [399KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX]
AHCA Form 3500-0011 [49KB, DOCX]
Proof of Financial Ability to Operate [173KB, XLS]
Patient Trust Surety Bond [53KB, DOCX]
|
Organ Procurement / Tissue Bank / Eye Bank
(Organ Procurement / Tissue Bank / Eye Bank webpage) |
Recommended Organ Procurement / Tissue Bank / Eye Bank Application Form [91KB, DOCX]
Recommended Organ Procurement / Tissue Bank / Eye Bank Application Checklist [51KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC] |
AHCA Form 3140-2001 [122KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX] |
Prescribed Pediatric Extended Care Centers
(Prescribed Pediatric Extended Care Centers webpage) |
Recommended Prescribed Pediatric Extended Care Centers Application Form[108KB, DOCX]
Recommended Prescribed Pediatric Extended Care Centers Application Checklist [113KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]
|
AHCA Form 3110-8002 [113KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOCX]
Proof of Financial Ability to Operate [361KB, XLS] |
Residential Treatment Centers for Children and Adolescents
(Residential Treatment Centers for Children and Adolescents webpage) |
Recommended Residential Treatment Centers Application Form [113KB, DOCX]
Recommended Residential Treatment Centers Application Checklist [61KB, DOCX]
Recommended Health Care Licensing Application Addendum [141KB, DOC]
HIV/AIDS Training Affidavit [22KB, PDF]
Community Residential Home Affidavit of Compliance [36KB, PDF] |
AHCA Form 3180-5004 [302KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOC] |
Transitional Living Facilities
(Transitional Living Facilities webpage) |
Recommended Transitional Living Facilities Application Form [101KB, DOCX]
Recommended Transitional Living Facilities Application Checklist [270KB, DOC]
Recommended Health Care Licensing Application Addendum [141KB, DOC] |
AHCA Form 3110-9001 [270KB, DOC]
AHCA Form 3110-1024 [126KB, DOC]
AHCA Form 3100-0008 [173KB, DOC] |
