Form Number | Name | For | Description |
---|---|---|---|
AHCA Form 3130-8001 |
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 |
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. |