Applications and Supporting Forms

Form Number	Name	For	Description
AHCA Form 3130-8001	Renew Online Health Care Licensing Application Hospitals	All application types	Standard Hospital application required to apply for, renew or modify a Hospital license.
AHCA Form 3110-1024	Health Care Licensing Addendum	Initial Renewal CHOW	Collects the confidential information to comply with the reporting requirements pursuant to Chapter 408, Part II, F.S.
AHCA Form 3130-8005	Comprehensive Emergency Management Planning Criteria for Hospitals [60KB, PDF]	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 3130-8012	Burn Unit Services Licensure Application [109KB, DOC]	Initial Designation	Form to attest the hospital meets burn unit services criteria specified in 59A-3.246(5), F.A.C. Attach to AHCA Form 3130-8001. Proof of Compliance with American Burn Association guidelines is required at license renewal.
AHCA Form 3130-5003	Adult Inpatient Diagnostic Cardiac Catheterization Licensure Application 108KB, DOC]	Initial Designation and Licensure Renewal	Form to attest adult inpatient diagnostic cardiac catheterization services meet the cri5teria in 59A-3.246(1), F.A.C. Attach to AHCA Form 3130-8001.
AHCA Form 3130-8010	Level I Adult Cardiovascular Services [116KB, DOC]	Initial Designation and Licensure Renewal	Form to attest adult cardiovascular services meet the criteria in 59A-3.246(2), F.A.C. Attach to AHCA Form 3130-8001.
AHCA Form 3130-8011	Level II Adult Cardiovascular Services [116KB, DOC]	Initial Designation and Licensure Renewal	Form to attest adult cardiovascular services meet the criteria in 59A-3.246(3), F.A.C. Attach to AHCA Form 3130-8001.
AHCA Form 3000-0001	Emergency Services Exemption Request Form [190KB, PDF]	Exemption Request	Application required for Hospital emergency services exemption requests. Attach to AHCA Form 3130-8001.
AHCA Form 3130-8013	Alternate-Site Testing License Application	Initial Renewal CHOW	Form recommended for reporting alternate-site testing within the hospital premises. Attach to AHCA Form 3130-8001.
	Certificate of Need	Initial	A written statement issued by the Agency evidencing community need for a new class 2, 3, or 4 hospital.
	Supplemental Information – Comprehensive Medical Rehabilitation Beds	Any bed change	A program description that outlines how the hospital will meet the current requirements of Rule 59C-1.039, F.A.C.
	Supplemental Information – Neonatal Intensive Care Beds	Any bed change	A program description that outlines how the hospital will meet the current requirements of Rule 59C-1.042, F.A.C.
	Supplemental Information – Heart Transplant Services	Initial Designation	A program description that outlines how the hospital will meet the current requirements of Rule 59C-1.044, F.A.C., related to heart transplantation programs.
	Supplemental Information – Liver Transplant Services	Initial Designation	A program description that outlines how the hospital will meet the current requirements of Rule 59C-1.044, F.A.C., related to liver transplantation programs.
	Supplemental Information – Kidney Transplant Services	Initial Designation	A program description that outlines how the hospital will meet the current requirements of Rule 59C-1.044, F.A.C., related to kidney transplantation programs.
	Supplemental Information – Bone Marrow Transplant Services	Initial Designation	A program description that outlines how the hospital will meet the current requirements of Rule 59C-1.044, F.A.C., related to bone marrow transplantation programs.
	Supplemental Information – Lung, Heart and Lung, Pancreas and Islet Cells, and Intestines Transplant Services	Initial Designation	A program description that outlines how the hospital will meet the current requirements of Rule 59C-1.044, F.A.C., related to lung, heart and lung, pancreas and islet cells, and intestines transplantation programs.
	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.
AHCA Form 3190-2000	Hospital Outpatient Observation Notice [56KB, DOCX]	Notification to patients on observation status	Form to be used to immediately notify a non-Medicare patient or the patient’s representative when a patient is placed on observation status. The signed version must be incorporated into the patient’s medical record and provided to the patient, patient’s survivor, or legal guardian through discharge papers.

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