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Health Care Policy and Oversight Application for Licensure Forms

Licensure, certification, and registration application forms for use by health care providers regulated under Chapter 408, Part II, Florida Statutes.

Licensure Forms For All Applicants As Required By Law

The following licensure application forms are for use by health care providers regulated under Chapter 408, Part II, Florida Statutes.

Licensure and/or certification forms for the following provider types may be found below:

Submit Online

Submit Online - Providers can submit renewal and change during licensure period applications through the Agency's Online Licensing System indicated below.  Initial applications for most provider types may also be submitted online.

Tips for submitting applications:

  • Make check/money order payable to the Agency for Health Care Administration (AHCA).
    • If payment is made out to the State of Florida or CLIA, it will be returned.
  • Payments for application fees must accompany the application.
    • If payment is not submitted with the application, it will be returned.
  • Renewal Applications must be submitted and paid prior to the expiration date.
    • Renewals may be submitted not more than 120 days before expiration.

Forms for All Provider Types

Forms for use by all provider types.

Health Care Licensing Application Addendum AHCA Form 3110-1024  Recommended Form [ word 140 kB ]  

Health Care Licensing Application Addendum AHCA Form 3110-1024  Form Authorized by Rule [ word 128.5 kB ]

Attestation of Compliance with Background Screening Requirements AHCA Form 3100-0008 [ word 177.2 kB ]

Forms for Multiple Provider Types

 

 

PROVIDER TYPERECOMMENDED FORMSFORMS AUTHORIZED BY RULE
Abortion Clinic
(Abortion Clinic webpage)

Recommended Abortion Clinic Application Form [ word 111.1 kB ]

Abortion Clinic Application Checklist [ word 53.3 kB ]

Recommended Health Care Licensing Application Addendum [ word 140 kB ]

Refusal to Permit Administration of Rho(D) Immune Globulin Form [ word 51.1 kB ]

AHCA Form 3130-1000 [ word 110.8 kB ]

Adult Day Care Center
(Adult Day Care Center webpage)

Recommended Adult Day Care Center Application Form [ word 115.6 kB ]

Adult Day Care Center Application Checklist [ word 67.5 kB ]

Specialty License Notification Form [ word 75 kB ]

Specialty License Affidavit of Compliance [ pdf 149.7 kB ]

ADCC Operator Identification [ pdf 57.7 kB ]

Recommended Health Care Licensing Application Addendum [ word 140 kB ]

Proof of Financial Ability to Operate [ excel 431 kB ]

AHCA Form 3180-1004 [ word 320.5 kB ]

 

Adult Family Care Home
(Adult Family Care Home webpage)

Recommended Adult Family Care Home Application [ word 270 kB ]

Adult Family Care Home Application Checklist [ word 62.8 kB ]

AFCH Local Zoning Form [ pdf 43.6 kB ]

Income and Expense Statement [ pdf 53.6 kB ]

Recommended Health Care Licensing Application Addendum [ word 140 kB ]

AHCA Form 3180-1022 [ word 195 kB ]
Ambulatory Surgical Center
(Ambulatory Surgical Center webpage)

Recommended Ambulatory Surgical Center Application Form [ word 122.6 kB ]

Ambulatory Surgical Center Application Checklist [ word 56.5 kB ]

Recommended Health Care Licensing Application Addendum [ word 140 kB ]

AHCA Form 3130-2001 [ word 108.4 kB ]
 
Assisted Living Facility
(Assisted Living Facility webpage)

Recommended Assisted Living Facility Application [ word 457.5 kB ]

Assisted Living Facility Application Checklist [ word 66.7 kB ]

Proof of Financial Ability to Operate:
ALFs  with 16 or Less Beds [ excel 243 kB ]
ALFs with 17 or More Beds [ excel 431 kB ]

Recommended Health Care Licensing Application Addendum [ word 140 kB ]

ALF Notification of Change of Administrator [ word 87 kB ]

AHCA Form 3110-1008 [ word 448.5 kB ]

 

Birth Center
(Birth Center webpage)

Birth Center Application Checklist [ word 55.5 kB ]

Recommended Health Care Licensing Application Addendum [ word 140 kB ]

Birth Center Licensure Application, AHCA Form 3130-3001 [ word 111.3 kB ]
Clinical Laboratory
(Non-Waived Lab webpage)

 

CLIA Application Form CMS-116 PDF[ application/pdf ]

 

 

Crisis Stabilization Unit/Short-Term Residential Treatment Facility 
(CSU / SRT webpage)

Recommended CSU/SRT Application Form [ word 116.2 kB ]

CSU/SRT Application Checklist [ word 61.7 kB ]

HIV/AIDS Training Affidavit [ pdf 21.2 kB ]

Recommended Health Care Licensing Application Addendum [ word 140 kB ]  

AHCA Form 3180-5003 [ word 319 kB ]
Drug-Free Workplace/Forensic Toxicology Laboratory
(Drug-Free Workplace/Forensic Toxicology Laboratory webpage)

Recommended Drug-Free Workplace/Forensic Toxicology Lab Application Form [ word 118.4 kB ]

Drug-Free Workplace/Forensic Toxicology Lab Application Checklist [ word 54 kB ]

Recommended Health Care Licensing Application Addendum [ word 140 kB ]

AHCA Form 3170-5001 [ word 143.6 kB ]
Health Care Clinic
(Health Care Clinic webpage)

Recommended Health Care Clinic Licensure Application Form [ word 118.7 kB ]

Health Care Clinic Application Checklist [ word 47 kB ]

Recommended Health Care Licensing Application Addendum [ word 140 kB ]  

Proof of Financial Ability to Operate [ excel 431 kB ]

Medical Clinic Director Attestation [ word 32.8 kB ]

 

Health Care Clinic Exemption from Licensure
(Health Care Clinic Exemption webpage)

 

Health Care Clinic Exemption Application Checklist [ word 49.7 kB ]

 

Health Care Clinic Exemption from Licensure Application, AHCA Form 3110-0014 [ word 79.3 kB ]
Health Care Services Pool
(Health Care Services Pool webpage)

Recommended Health Care Services Pool Application Form [ word 305 kB ]

Health Care Services Pool Application Checklist [ word 50 kB ]

Recommended Health Care Licensing Application Addendum [ word 140 kB ]

AHCA Form 3110-1010 [ word 99.5 kB ]
Home Health Agency
(Home Health Agency webpage)

Recommended Home Health Agency Application Form [ word 131.2 kB ]

Home Health Agency Application Checklist [ word 61.2 kB ]

Recommended Health Care Licensing Application Addendum [ word 140 kB ]  

Proof of Financial Ability to Operate [ excel 431 kB ]

AHCA Form 3110-1011 [ word 115.2 kB ]

Excellence in Home Health Award Application, AHCA Form 3110-9002 [ word 82.1 kB ]

Home Health Agency Exemption from Licensure
(Home Health Agency webpage)

 

Home Health Agency Exemption Application Checklist [ word 56.5 kB ]

 

Home Health Agency Exemption Application Form [ word 90.1 kB ]
Home Medical Equipment Provider
(Home Medical Equipment Provider webpage)

Recommended Home Medical Equipment Provider Application Form [ word 146.6 kB ]

Home Medical Equipment Provider Application Checklist [ word 78.8 kB ]

Recommended Health Care Licensing Application Addendum [ word 140 kB ]

Proof of Financial Ability to Operate [ excel 431 kB ]

Request for Change of Name and/or Address [ word 56 kB ]

 

Homemaker & Companion Services Provider
(Homemaker & Companion Services Provider webpage)

Recommended Homemaker & Companion Services Provider Application Form [ word 106.3 kB ]

Homemaker & Companion Services Provider Application Checklist [ word 68.5 kB ]

Recommended Health Care Licensing Application Addendum [ word 140 kB ]  

AHCA Form 3110-1003 [ word 108.7 kB ]
Hospice
(Hospice webpage)

Recommended Hospice Application Form [ word 131 kB ]

Hospice Application Checklist [ word 69.5 kB ]

Recommended Health Care Licensing Application Addendum [ word 140 kB ]  

Proof of Financial Ability to Operate [ excel 431 kB ]

Attestation of Compliance with Applicable Life Safety Codes for Additions to Existing Hospice Inpatient Facilities/Residential Units [ word 59 kB ]

AHCA Form 3110-4001 [ word 127.1 kB ]

 

Hospital
(Hospital webpage)

Hospital Application Checklist [ word 69.2 kB ]

Recommended Health Care Licensing Application Addendum  [ word 140 kB ]

Hospital Licensure Application, AHCA Form 3130-8001 [ word 160.4 kB ]

Hospital Outpatient Observation Notice [ word 55.4 kB ]

Licensing Application Alternate-Site Testing [ word 60.6 kB ]

Emergency Services Exemption Request Form, AHCA Form 3000-0001 [ pdf 189.2 kB ]

Burn Unit Services Application Form, AHCA Form 3130-8012 [ word 108.5 kB ]

Adult Inpatient Diagnostic Cardiac Catheterization Services Application Form, AHCA Form 3130-5003 [ word 108 kB ]

Level I Adult Cardiovascular Services Application Form, AHCA Form 3130-8010 [ word 115.5 kB ]

Level II Adult Cardiovascular Services Application Form, AHCA Form 3130-8011 [ word 116 kB ]

Intermediate Care Facility for the Developmentally Disabled
(Intermediate Care Facility for the Developmentally Disabled webpage)

ICF/DD Application Checklist [ word 69 kB ]

Recommended Health Care Licensing Application Addendum [ word 140 kB ]  

Proof of Financial Ability to Operate [ excel 431 kB ]

ICF/DD Licensure Application, AHCA Form 3110-5003 [ word 113.1 kB ]

 

Nurse Registry
(Nurse Registry webpage)

Recommended Nurse Registry Application Form [ word 107.1 kB ]

Nurse Registry Application Checklist [ word 60.1 kB ]

Recommended Health Care Licensing Application Addendum [ word 140 kB ]

Nurse Registry Proof of Financial Ability to Operate [ excel 185.5 kB ]

AHCA Form 3110-7004 [ word 93.9 kB ]

AHCA Form 3110-7004CL [ word 55.8 kB ]

Nursing Home
(Nursing Home webpage)

Recommended Nursing Home Application Form [ word 131.1 kB ]

Nursing Home Application Checklist [ word 80.1 kB ]

Medicaid Lease Bond [ pdf 8.8 kB ]

Unconditional Guarantee of Payment [ pdf 9.9 kB ]

Gold Seal Application [ word 62.6 kB ]

Recommended Health Care Licensing Application Addendum [ word 140 kB ]  

Proof of Financial Ability to Operate [ excel 431 kB ]

Patient Trust Surety Bond [ word 53 kB ]

AHCA Form 3110-6001 [ word 117.3 kB ]

 

Organ Procurement / Tissue Bank / Eye Bank
(Organ Procurement / Tissue Bank / Eye Bank webpage)

Recommended Organ Procurement / Tissue Bank / Eye Bank Application Form [ word 90 kB ]

Organ Procurement / Tissue Bank / Eye Bank Application Checklist [ word 51.5 kB ]

Recommended Health Care Licensing Application Addendum [ word 140 kB ]  

AHCA Form 3140-2001 [ word 121.5 kB ]
Prescribed Pediatric Extended Care Centers
(Prescribed Pediatric Extended Care Centers webpage)

Recommended Prescribed Pediatric Extended Care Centers Application Form [ word 106 kB ]

Prescribed Pediatric Extended Care Centers Application Checklist [ word 71.7 kB ]

Recommended Health Care Licensing Application Addendum [ word 140 kB ]

Proof of Financial Ability to Operate [ excel 431 kB ]

AHCA Form 3110-8002 [ word 112.9 kB ]

 

Residential Treatment Centers for Children and Adolescents
(Residential Treatment Centers for Children and Adolescents webpage)

Recommended Residential Treatment Centers Application Form [ word 114.7 kB ]

Residential Treatment Centers Application Checklist [ word 65.4 kB ]

HIV/AIDS Training Affidavit [ pdf 21.2 kB ]

Community Residential Home Affidavit of Compliance [ pdf 35.3 kB ]

Recommended Health Care Licensing Application Addendum [ word 140 kB ]

AHCA Form 3180-5004 [ word 113.7 kB ]
Residential Treatment Facility
(RTF webpage)

Recommended RTF Application Form [ word 110.7 kB ]

RTF Application Checklist [ word 62.7 kB ]

HIV/AIDS Training Affidavit [ pdf 21.2 kB ]

Local Zoning Form (Levels I-A, I-B, and II) [ pdf 31.7 kB ]

Recommended Health Care Licensing Application Addendum [ word 140 kB ]

AHCA Form 3180-5003 [ word 319 kB ]
Transitional Living Facilities
(Transitional Living Facilities webpage)

Recommended Transitional Living Facilities Application Form [ word 109.9 kB ]

Transitional Living Facilities Application Checklist [ word 64.9 kB ]

Recommended Health Care Licensing Application Addendum [ word 140 kB ]

AHCA Form 3110-9001 [ word 100.6 kB ]