Health Facilities and Providers

The following licensure application forms are for use by health care providers regulated under Chapter 408, Part II, Florida Statutes. Forms are required pursuant to section 59A-35.060, Florida Administrative Code.

LICENSURE FORMS REQUIRED FOR ALL APPLICANTS AS APPLICABLE

NOTICE

Changes in law effective August 1 requires revisions to licensure application forms and fees for some provider types. The processing of level 2 background screening has also been revised for all applications.


Please use the recommended forms below when submitting an application for licensure.

The forms are interactive, unless otherwise noted, and may be filled out by typing into the form. When completed please print and mail the application and any supporting documents to the Agency.

Licensure applications and fees may be returned or delayed if submitted too early or certain items are missing.
Avoid having your application or fees returned by:

  • Including a check or money order with your application. (Fees must accompany the application).
  • Using a regular, pre-printed check. (Starter checks from new bank accounts are not accepted).
  • Making the check or money order payable to the Agency for Health Care Administration (AHCA).
  • Not submitting a renewal application more than 120 days before the expiration date.
  • For clinical laboratories – Do not send a check payable to CLIA.

FORMS USED BY PROVIDERS AS REQUIRED BY LAW

REQUIRED BY
RECOMMENDED FORM
Reflects changes in 2010 legislation
FORMS AUTHORIZED BY RULE
All Providers

Health Care Licensing Application Addendum (127 kb DOC)

Affidavit of Compliance with Background Screening Requirements (102 kb DOC)

AHCA Form 3110-1024 (126 kb DOC)

AHCA Form 3100-0008 (126 kb DOC)

Providers as required by law

 Proof of Financial Ability to Operate (353 kb XLS) AHCA Form 3100-0009 (353 kb XLS)

HEALTH CARE LICENSING APPLICATIONS BY PROVIDER TYPE
REQUIRED BY
RECOMMENDED FORM
Reflects changes in 2010 legislation
FORMS AUTHORIZED BY RULE
Abortion Clinic Abortion Clinic Recommended Application Form (322kb DOC)
Abortion Clinic Recommended Application Form (470kb PDF)
The following CPI applications should be used for providers renewing or applying on or after September 1, 2013:
Abortion Clinic CPI (135kb DOC)
Abortion Clinic CPI (470kb PDF) 		AHCA Form 3130-1000 (311kb DOC)
Adult Day Care Center Adult Day Care Center Recommended Application Form (326 kb DOC)

Adult Day Care Center Operator Identification Statement(65 kb DOC)

Adult Day Care Local Zoning Form (72 kb DOC)

Specialty License Notification Form (70 kb DOC)

The following CPI applications should be used for providers renewing or applying on or after September 1, 2013:
Adult Day Care Center CPI (326 kb DOC)

AHCA Form 3180-1004
(321 kb DOC)

AHCA Form 3180-1036
(65 kb DOC)

AHCA form 3180-1021
(72 kb DOC)

Adult Family Care Home

Adult Family Care Home Recommended Application Form
(195 kb DOC)

Adult Family Care Home Local Zoning Form (72 kb DOC)

The following CPI applications should be used for providers renewing or applying on or after September 1, 2013:
Adult Family Care Home CPI (212 kb DOC)

AHCA Form 3180-1022 (195 kb DOC)


AHCA Form 3180-1021 (72 kb DOC)
Ambulatory Surgical Center Ambulatory Surgical Center Recommended Application Form (359 kb DOC)
Ambulatory Surgical Center Recommended Application Form (479 kb PDF)
The following CPI applications should be used for providers renewing or applying on or after September 1, 2013:
Ambulatory Surgical Center CPI (146 kb DOC)
Ambulatory Surgical Center CPI (479 kb PDF)

AHCA Form 3130-2001 (354 kb DOC)
Assisted Living Facility

Assisted Living Recommended Application Form (387 kb DOC)

Proof of Financial Ability to Operate for ALFs with 16 or Less Beds (107 kb XLS)

ALF Affidavit of Compliance Community Residential Home (102 kb DOC)

Assisted Living Local Zoning Form (71 kb DOC)

ALF Notification of Change of Administrator (76 kb DOC)

The following CPI applications should be used for providers renewing or applying on or after September 1, 2013:
Assisted Living Facility CPI (388 kb DOC)

AHCA Form 3110-1008 (355 kb DOC)

Affidavit of Compliance (102 kb DOC)

AHCA Form 3180-1021 (71 kb DOC)

AHCA Form 3180-1006 (76 kb DOC)
Birth Center Birth Center Recommended Application Form (doc) (327kb)
Birth Center Recommended Application Form (396kb)
The following CPI applications should be used for providers renewing or applying on or after September 1, 2013:
Birth Center CPI (135kb DOC)
Birth Center CPI (396kb PDF)		 AHCA Form 3130-3001 (327 kb DOC)
Clinical Laboratory
(Non-Waived)

Clinical Laboratory Recommended Application Form (627 kb DOC)
Clinical Laboratory Recommended Application Form (1.28 MB PDF)

Addition of Speciality Services Application, AHCA Form 3170-2004D (376 kb DOC)
Addition of Speciality Services Application, AHCA Form 3170-2004D (947 kb PDF)

Initial Application, AHCA Form 3170-2004B (585 kb DOC)
Initial Application, AHCA Form 3170-2004B (914 kb PDF)

CHOW Application, AHCA Form 3170-2004C (573 kb DOC)
CHOW Application, AHCA Form 3170-2004C (966 kb PDF)

Renewal Application, AHCA Form 3170-2004 (570 kb DOC)
Renewal Application, AHCA Form 3170-2004 (710 kb PDF)
Drug Free Workplace Laboratory Drug Free Workplace Lab Recommended Application Form (397 kb DOC)
Drug Free Workplace Lab Recommended Application Form (1.48 MB PDF)		 AHCA Form 3170-5001 (348 kb DOC)
Health Care Clinic Health Care Clinic Recommended Application Form (549 kb DOC) AHCA Form 3110-0013(384 kb DOC)
Health Care Clinic Exemption for Licensure Health Care Clinic Exemption Recommended Application Form (294 kb DOC) AHCA Form 3110-0014 (250 kb DOC)
Health Care Risk Manager Health Care Risk Manager Recommended Application Form (199kb DOC)
Health Care Risk Manager Recommended Application Form (315kb PDF)
The following CPI applications should be used for providers renewing or applying on or after September 1, 2013:
Risk Manager CPI (81kb DOC)
Risk Manager CPI (315kb PDF)		 AHCA Form RM-001 (194 kb DOC)
Health Care Services Pool Health Care Services Pool Recommended Application Form (292 kb DOC) AHCA Form 3110-1010(308 kb DOC)
Home Health Agency Home Health Agency Recommended Application Form (464 kb DOC) AHCA Form 3110-1011 (440 kb DOC)
Home Medical Equipment Provider Home Medical Equipment Recommended Application Form (478 kb DOC)
The following CPI applications should be used for providers renewing or applying on or after September 1, 2013:
Home Medical Equipment CPI (175 kb DOC)		 AHCA Form 3110-1005 (481 kb DOC)
Home for Special Services Home For Special Services Recommended Application Form (277 kb DOC)
The following CPI applications should be used for providers renewing or applying on or after September 1, 2013:
Home For Special Services CPI (291 kb DOC) 		AHCA Form 3110-3001 (278 kb DOC)
Homemaker Companion Services Homemaker Companion Services Recommended Application Form (230 kb DOC)
The following CPI applications should be used for providers renewing or applying on or after September 1, 2013:
Homemaker Companion Services CPI (94 kb DOC)		 AHCA Form 3110-1003 (227 kb DOC)
Hospice Hospice Recommended Application Form (407 kb DOC)
The following CPI applications should be used for providers renewing or applying on or after September 1, 2013:
Hospice CPI (163 kb DOC)		 AHCA Form 3110-4001 (412 kb DOC)
Hospital Hospital Recommended Application Form (502 kb DOC)
Hospital Recommended Application Form(554 kb PDF)
The following CPI applications should be used for providers renewing or applying on or after September 1, 2013:
Hospitals CPI (167kb DOC)
Hospitals CPI (554kb PDF)		 AHCA Form 3130-8001 (472 kb DOC)
Intermediate Care Facility for the Developmentally Disabled ICF-DD Recommended Application Form(335 kb DOC)
The following CPI applications should be used for providers renewing or applying on or after September 1, 2013:
Intermediate Care Facility for the Developmentally Disabled CPI (353 kb DOC)		 AHCA Form 3110-5003 (333 kb DOC)

Mental Health Services -

CSU / SRT

RTF

 Mental Health Services - CSU/SRT/RTF (339 kb DOC)
Mental Health Services -CSU/SRT/RTF (299 kb PDF)
The following CPI applications should be used for providers renewing or applying on or after September 1, 2013:
Mental Health Services - CSU/SRT/RTF CPI (140 kb DOC)
Mental Health Services - CSU/SRT/RTF CPI (299 kb PDF)

AHCA Form 3180-5003 (319 kb DOC)

AHCA Form 3180-5003 (267 kb PDF)
Multiphasic Health Testing Center Multiphasic Health Testing Center Recommended Application Form (336 kb DOC)
Multiphasic Health Testing Center Recommended Application Form (777 kb PDF)		 AHCA Form 3170-4001 (327 kb DOC)
Nurse Registry Nurse Registry Recommended Application Form (335 kb DOC) AHCA Form 3110-7004(322 kb DOC)
Nursing Home

Nursing Home Recommended Application Form (419 kb DOC)

Medicaid Lease Bond not interactive (9 kb PDF)

Patient Trust Surety Bond (63 kb DOC)

Unconditional Guarantee of Payment not interactive (10 kb PDF)

AHCA Form 3110-6001 (399 kb DOC)

AHCA Form 3110-6002 (63 kb DOC)

AHCA Form 3110-6009 (9 kb PDF)
AHCA Provider Form (10 kb PDF)
Organ Procurement / Tissue Bank / Eye Bank Organ Procurement / Tissue Bank / Eye Bank
Recommended Application Form (335 kb DOC)
Organ Procurement / Tissue Bank / Eye Bank
Recommended Application Form (756 kb PDF) 		AHCA Form 3140-2001 (323 kb DOC)
Prescribed Pediatric Extended Care Centers Prescribed Pediatric Extended Care Centers
Recommended Application Form (280 kb DOC)
The following CPI applications should be used for providers renewing or applying on or after September 1, 2013:
Prescribed Pediatric Extended Care Centers CPI (301 kb DOC)		 AHCA Form 3110-8002 (287 kb DOC)
Residential Treatment Centers for Children and Adolescents Residential Treatment Centers Recommended Application Form (300 kb DOC)
Residential Treatment Centers Recommended Application Form (472 kb PDF)

AHCA Form 3180-5004(302 kb DOC)

AHCA Form 3180-5004 (472 kb PDF)
Transitional Living Facilities Transitional Living Facilities Recommended Application Form (279 kb DOC) AHCA Form 3110-9001 (281 kb DOC)
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