Applications and Supporting Forms
| Form Number | Name | For | Description |
|---|---|---|---|
| AHCA Form 3130-8001 | Renew Online Health Care Licensing Application Hospitals | All application types | Standard 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
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60.2 kB
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| 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 3000-0001 |
Emergency Services Exemption Request Form
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189.2 kB
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| 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. |
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Supplemental Information – Comprehensive Medical Rehabilitation Beds
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104.7 kB
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| 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 – Heart Transplant Services
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114.9 kB
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| 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. | |
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Supplemental Information – Liver Transplant Services
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115.1 kB
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| 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
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117.5 kB
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| 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
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126.8 kB
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| 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
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114.6 kB
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| 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 Addition or change to the address of a hospital-based off-campus emergency dept or surgery center | 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 to AHCA, and indicating who will pay and when. | |
| AHCA Form 3190-2000 |
Hospital Outpatient Observation Notice
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55.3 kB
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| 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. |
| AHCA Form 3180-5007 November 2024 Recommended Form |
Behavioral Health Teaching Hospital Grant Application
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| Qualified hospitals may submit the application, a detailed spending plan, and supporting documentation during the open application period as specified in 395.903, F.S. | Grant funding may be used for operations and expenses and for fixed capital outlay, including, but not limited to, facility renovation and upgrades. |
| Grant Funding Agreement |
Grant Agreement Sample
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1.2 MB
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| The grant funding agreement would require execution if awarded a grant. |
