*PLEASE NOTE -THE AGENCY ENCOURAGES ALL APPLICANTS TO USE THIS SERVICE*
The Agency for Health Care Administration (AHCA) has implemented its new ONLINE LICENSING SYSTEMwhich allowselectronic submission of renewal applications and fees, along with the ability to upload supporting documentation. To renew online please go to:
This application checklist is for informational purposes only – to be used as a guide for applicants when completing the licensing application process. All forms listed below may be obtained from the website:
Send completed applications to: Agency for Health Care Administration, Home Care Unit, 2727 Mahan Drive, Mail Stop 34, Tallahassee, FL 32308.
APPLICATION TYPES AND DEFINITIONS:
Initial (I) – application for an initial license/registration/certification
Renewal (R) – biennial renewal of existing license/registration/certification
Change of Ownership (CHOW) – change of 51% or more of the ownership OR licensee sells/transfers ownership to a different individual/entity
Change during Licensure Period (CL) – request to amend /change information that displays on the license
- Name Change (CL/N)
- Address Change (CL/A) – includes the following types:
- Main Office – (CL/AM)
- Satellite Office (addition) – (CL/ASOA)
- Satellite Office (closure) – (CL/ASOC)
- Counties Served (add/delete) – (CL/AC)
Change during Licensure Period (CNL) – request to amend /change information that does notdisplay on the license
- Stock Transfer of less than 51% (CNL/ST)
- Personnel Change (CNL/P)
- Drop-off Site (CNL/DS)
- Hours of Operation (CNL/OP)
- Service Change (skilled to non-skilled or vice versa) – (CNL/SV)
In order to provide the Agency with a complete application and expedite the licensure process, it may be helpful to gather the following information:
Provider Information- (Application Types: All)
Street address, mailing address, email address, website address, telephone number, fax number and Medicaid, Medicare and National Provider Identifier (NPI) numbers (if applicable)
Licensee (Owner)Information(Application Types: All)
Organization type, complete legal name, mailing address, EIN/SSN, email address, telephone number, and fax number. Legal name and address submitted with application must be the same that is registered with Department of State, Division of Corporations
Contact Person(Application Types: All)
Name, email address, telephone number, and fax number
Licensee Controlling Interests, Board Members, and Officers(Application Types: I, R, CHOW, CNL/ST)
Name, EIN/SSN, date of birth, personal mailing address, email address, telephone number, fax number, and % ownership interest for each controlling interest, board member and officer
Management Company, (if applicable)(Application Types: I, R, CHOW, CNL/ST)
Name, EIN, street address, mailing address, email address, telephone number, and fax number
Management Company Controlling Interests, Board Members, and Officer (Application Types: I, R, CHOW, CNL/ST)
Name, EIN/SSN, date of birth, personal mailing address, email address, telephone number, fax number, and % ownership interest for each controlling interest, board member and officer
Personnel (Application Types: I, R, CHOW, CNL/P if applicable)
Name, SSN, date of birth, personal mailing address, email address, telephone number, fax number, Florida healthcare license number (if applicable) and effective date of employment
Required Disclosure (Application Types: I, R, CHOW)
Legal information (if any) for licensee, licensee controlling interests, management company, and management company controlling interests
Provider Fines and Financial Information (Application Types: I, R, CHOW)
Assessing entities, related case numbers, dates of assessment, final orders, next payment due dates of any monies owed to the Agency (AHCA)
Services (Application Types: I, R, CHOW, CL/SV if applicable)
Patient census, skilled services to children, non-skilled services and number of direct and contracted employees including name of contracted agency if applicable
Geographic Service Area(Application Types: I, R, CHOW, CL/AC if applicable)
Counties served
Other Associated Locations(Application Types: I, R, CHOW, CL/ASOA if applicable))
Satellite Office street address, city zip, county, telephone number
Drop-Off Site street address, city zip, county
Days and Hours of Operation(Application Types: I, R, CHOW, CNL/OP if applicable))
Days of the week, opening time and closing time
Accreditation/Deemed Status(Application Types: I, R, CHOW)
Accreditation information including name of accrediting organization, effective and expiration dates of accreditation
Supporting Documents (Application Types: All, unless otherwise specified)
Proof of current general liabilityand malpractice insurance coverage - (Application Types: All)
Surety or continuation bond - (Application Types: All – for applicants that check YES on section 6.D. on the home health agency application only)
Proof of current accreditation - documentation and survey report - (Application Types: I, R, CHOW,CL/A )
Proof of financial ability to operate - Evidence of sufficient funds to operate such as bank statements, net worth statements or financial reports. – (Application Types: I and CHOW)
Business plan, signed by the applicant, detailing the home health agency’s methods to obtain patients and its plan to recruit and maintain staff- (Application Types: I, CHOW)
Facility ownership/lease documentation (if applicable)(Application Types: I, CHOW, CL/A)
Documentation signed by the appropriate local government official, which states that the applicant has met local zoning requirements - (Application Types: I, CHOW, CL/A)
Plan for delivery of services per Rule 59A-8.007(2), F.A.C- (Application Types: CL/A, for addition of satellite office(s) only)
Documentation of change of ownership transaction stating effective date and executed by all parties - (Application Types: CHOW, CNL/ST)
Health Care Licensing Application Addendum, AHCA Form 3110-1024- (Application Types: I, R, CHOW)
Fire safety inspection report - (Application Types: I, CHOW, CL/A
Attestation of compliance with background screening requirementsif background screening was conducted by the Department of Health, the Agency for Person with Disabilities, the Department of Children and Families, Department of Elder Affairs or the Department of Financial Services (if applicable)(Application Types: I, R, CHOW, CNL/P)
Copy of exemption from disqualification for documented offenses (if applicable) – (Application Types: All)
Required disclosures related to actions taken by Medicare, Medicaid or CLIA, if applicable - (Application Types: All, if documentation is required due to responses provided in application)
Approved repayment plan (if applicable)
Attestation(Application Types: All)
Licensee or authorized representative
Biennial Licensure Fee and Other Amounts Due Upon Submission of Application
The biennial licensure fee is $1,705.
The biennial assessment fee is $2 per bed (annual fee of $1 per bed x 2 years) not to exceed $300 per facility (annual cap of $150 x 2 years)
The replacement license certificate fee is $25.
Other amounts due (fines, assessment, fees, etc.) will be detailed in the application
The Agency for Health Care Administration scans all documents for electronic storage. In an effort to facilitate this process, we ask that you please remember to:- Please place checks or money orders on top of the application
- Include license number or case number on your check
- Do not submit carbon copies of documents
- Do not fold any of the documents being submitted
- No staples, paperclips, binder clips, folders, or notebooks
- Please do not bind any of the documents submitted to the Agency.
AHCA Form 3110-1011CL, March 2016 Form available at:
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