HOSPITAL BED UTILIZATION - FL Agency for Health Care ...



7553711529400485965595885AHCA USE ONLY:File #: Application #: Check #: Check Amt: Batch #: 00AHCA USE ONLY:File #: Application #: Check #: Check Amt: Batch #: Health Care Licensing ApplicationHospitalsThe Agency for Health Care Administration (AHCA) has implemented the ONLINE LICENSING SYSTEM, which allows the electronic submission of renewal and change during licensure period applications and fees, along with the ability to upload supporting documentation. To submit online please go to: must be received at least 60 days prior to the expiration of the current license or effective date of a change of ownership to avoid a late fee. If the renewal application is received by the Agency less than 60 days prior to the expiration date, it is subject to a late fee as set forth in statute. The applicant will receive notice of the amount of the late fee as part of the application process or by separate notice. The application will be withdrawn from review if all the required documents and fees are not included with your application or received within 21 days of an omission notice. Applications will not be considered for review until payment has been received. Renewal and Change During Licensure applications: Supporting documentation, responses to omissions and payments may be submitted using the online system even if the application was originally mailed to the Agency.Under the authority of Chapters 408 Part II, and 395 Florida Statutes (F.S.), and Chapters 59A-35, and 59A-3, Florida Administrative Code (F.A.C.), an application is hereby made to operate a hospital as indicated below:1.Provider / Licensee InformationA. PROVIDER INFORMATION – Please complete the following for the hospital name and location. Provider name, address and telephone number will be listed on # (if applicable) FORMTEXT ?????National Provider Identifier (NPI) (if applicable) FORMTEXT ?????Florida Medicaid #(if applicable) FORMTEXT ?????Name of Hospital (if operated under a fictitious name, enter as it appears in Florida Division of Corporations) FORMTEXT ?????Street Address FORMTEXT ?????City FORMTEXT ?????County FORMTEXT ?????State FORMTEXT ?????Zip FORMTEXT ?????Telephone Number FORMTEXT ?????Fax Number FORMTEXT ?????Mailing Address or FORMCHECKBOX Same as above FORMTEXT ?????City FORMTEXT ?????County FORMTEXT ?????State FORMTEXT ?????Zip FORMTEXT ?????Telephone Number FORMTEXT ?????E-mail Address FORMTEXT ?????NOTE: By providing your e-mail address you agree to accept e-mail correspondence from the Agency.Provider Home Website FORMTEXT ?????Provider Transparency Website in accordance with s. 395.301, F.S. FORMTEXT ?????B. PROPERTY OWNER INFORMATION – Complete the following for the owner of the property if different from the licensee.Does an individual or entity other than the licensee own the property where the principal office is located?If FORMCHECKBOX NO, skip to section 2 – Application Type and FeesIf FORMCHECKBOX YES, please provide the following information:Full Name Of Property OwnerPersonal/Primary AddressTelephone Number FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????C. CONTACT PERSON - Please complete the following for the contact person for this application.Contact Person for this application FORMTEXT ?????Contact Telephone Number FORMTEXT ?????Contact e-mail address or FORMCHECKBOX Do not have e-mail FORMTEXT ?????NOTE: By providing your e-mail address you agree to accept e-mail correspondence from the Agency.D. LICENSEE INFORMATION –Please complete the following for the entity seeking to operate the hospital.Licensee Name (owner) FORMTEXT ?????Federal Employer Identification Number (EIN) FORMTEXT ?????Mailing Address or FORMCHECKBOX Same as above FORMTEXT ?????City FORMTEXT ?????State FORMTEXT ?????Zip FORMTEXT ?????Telephone Number FORMTEXT ?????Fax Number FORMTEXT ?????E-mail Address FORMTEXT ?????Description of Licensee (check one):For ProfitNot for ProfitPublic FORMCHECKBOX Corporation FORMCHECKBOX Corporation FORMCHECKBOX State FORMCHECKBOX Limited Liability Company FORMCHECKBOX Religious Affiliation FORMCHECKBOX City/County FORMCHECKBOX Partnership FORMCHECKBOX Other FORMCHECKBOX Hospital District FORMCHECKBOX Individual FORMCHECKBOX Sole Proprietor FORMCHECKBOX Other2.Application Type and FeesIndicate the type of application with an “X.” Applications will not be processed if not all applicable fees are included. Pursuant to subsection 408.805(4), F.S., fees are nonrefundable. Renewal and Change of Ownership applications must be received 60 days prior to the expiration of the license or the proposed effective date of the change to avoid a late fee. If the renewal application is received by the Agency less than 60 days prior to the expiration date, it is subject to a late fee as set forth in statute. The applicant will receive notice of the amount of the late fee as part of the application process or by separate notice.A.TYPE OF APPLICATION FORMCHECKBOX Initial licensureProposed effective date: FORMTEXT __________________Was this entity previously licensed as a hospital? YES FORMCHECKBOX NO FORMCHECKBOX If YES, please provide the name of the agency (if different), the EIN # and the year the prior license expired or closed: NAME: FORMTEXT ????? EIN # FORMTEXT ?????Year Expired/Closed: FORMTEXT ????? FORMCHECKBOX Renewal licensure FORMCHECKBOX Change of OwnershipProposed effective date: FORMTEXT __________________ FORMCHECKBOX Owner Change FORMCHECKBOX Stock Transfer of greater than 51% FORMCHECKBOX Change during licensure period (check all that apply): Proposed effective date: FORMTEXT __________________Fee RequiredNo Fee Required FORMCHECKBOX Provider Name FORMCHECKBOX PersonnelProvider Address: FORMCHECKBOX Management Company FORMCHECKBOX Hospital Address FORMCHECKBOX Baker Act Receiving Facility Designation FORMCHECKBOX Offisite Emergency Department FORMCHECKBOX Add FORMCHECKBOX Delete FORMCHECKBOX Add FORMCHECKBOX Delete FORMCHECKBOX Offisite Outpatient Location FORMCHECKBOX Add FORMCHECKBOX Delete FORMCHECKBOX Change of Controlling Interest, less than 51%Services/Qualifications: FORMCHECKBOX Licensed Programs FORMCHECKBOX Add FORMCHECKBOX Delete FORMCHECKBOX Emergency Services FORMCHECKBOX Add FORMCHECKBOX Delete FORMCHECKBOX Exemption Request FORMCHECKBOX Trauma Center Designation FORMCHECKBOX Add FORMCHECKBOX Delete Beds/Capacity: FORMCHECKBOX Increase FORMCHECKBOX Decrease FORMCHECKBOX Conversion FORMCHECKBOX Replacement LicenseB.LICENSURE FEESACTIONFEETOTAL FEESLicense Fee (Initial, Renewal and Change of Ownership)$31.46 per bed x FORMTEXT ????? number of beds = (minimum of $1,565.13)$ FORMTEXT ?????Initial licensure survey fee (Initial applications only)$12.00 per bed x FORMTEXT ????? number of beds =(minimum of $400.00)$ FORMTEXT ?????Increase in Number of Licensed Beds$31.46 per bed x FORMTEXT ????? number of new beds =$ FORMTEXT ?????Biennial Assessment (Initial, Renewal and Change of Ownership) Pursuant to section 408.033(2) (b) 3. F.S., hospitals operated by the Department of Children and Family Services, the Department of Health, the Department of Corrections or any hospital that meets the definition of a rural hospital pursuant to section 395.602, F.S., are exempted from the health care facility assessment.$4.00 per bed x FORMTEXT ????? number of beds =(maximum of $1,000.00)$ FORMTEXT ?????Change During Licensure Period/Replacement License$ 25.00$ FORMTEXT ?????Other: FORMTEXT ?????$ FORMTEXT ?????TOTAL FEES INCLUDED WITH APPLICATION$ FORMTEXT ?????Please make check or money order payable to the Agency for Health Care Administration (AHCA)3.Controlling Interests of LicenseeAUTHORITY: Pursuant to section 408.806(1)(a) and (b), F.S., an application for licensure must include: the name, address and social security number (SSN) of the applicant and each controlling interest, if the applicant or controlling interest is an individual; and the name, address, and federal employer identification number (EIN) of the applicant and each controlling interest, if the applicant or controlling interest is not an individual. Disclosure of social security number(s) is mandatory. The Agency for Health Care Administration shall use such information for purposes of securing the proper identification of persons listed on this application for licensure. However, in an effort to protect all personal information, do not include social security numbers on this form. All social security numbers must be entered on the Health Care Licensing Application Addendum, AHCA Form 3110-1024.DEFINITIONS: Controlling interests, as defined in section 408.803(7), F.S., are the applicant or licensee; a person or entity that serves as an officer of, is on the board of directors of, or has a 5% or greater ownership interest in the applicant or licensee; or a person or entity that serves as an officer of, is on the board of directors of, or has a 5% or greater ownership interest in the management company or other entity, related or unrelated, with which the applicant or licensee contracts to manage the provider. The term does not include a voluntary board member.Note: For each controlling interest an AHCA screening through the Care Provider Background Screening Clearinghouse is needed or the Attestation of Compliance with Background Screening Requirements, AHCA Form 3100-0008 if background screening was conducted by the Department of Financial Services for an applicant for a certificate of authority to operate a continuing care retirement community under Chapter 651, F.S. To verify who is to be screened, visit HYPERLINK "" . Individual and/or Entity Ownership of Licensee as listed in section 1D above – Provide the information for each individual or entity (corporation, partnership, association) with 5% or greater ownership interest in the licensee. Attach additional sheets if necessary. Note: This excludes Not-for-Profit and publicly held licensees.FULL NAME of INDIVIDUAL or ENTITYPERSONAL/PRIMARY ADDRESSTELEPHONE NUMBEREIN(No SSN)% OWNERSHIPEFFECTIVE DATEEND DATE FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Board Members and Officers of Licensee – Provide the information for each individual or entity (corporation, partnership, association) that serves as an officer or is on the board of directors. Do not include voluntary board members.TITLEFULL NAMEPERSONAL/PRIMARY ADDRESSTELEPHONE NUMBEREFFECTIVE DATEEND DATEBoard Member/Officer FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Board Member/Officer FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Board Member/Officer FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Board Member/Officer FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????4.Management Company ControlDoes a company other than the licensee manage the licensed provider?If FORMCHECKBOX NO, skip to section 5 PersonnelIf FORMCHECKBOX YES, provide the following information:Name of Management Company FORMTEXT ?????EIN (No SSN) FORMTEXT ?????Telephone Number / Fax FORMTEXT ?????Street Address FORMTEXT ?????E-mail Address FORMTEXT ?????City FORMTEXT ?????County FORMTEXT ?????State FORMTEXT ?????Zip FORMTEXT ?????Mailing Address or FORMCHECKBOX Same as above FORMTEXT ????? City FORMTEXT ?????State FORMTEXT ?????Zip FORMTEXT ?????Contact Person FORMTEXT ?????Contact E-mail FORMTEXT ?????Contact Telephone Number FORMTEXT ?????DEFINITION: Controlling interests, as defined in section 408.803(7), F.S., are the applicant or licensee; a person or entity that serves as an officer of, is on the board of directors of, or has a 5% or greater ownership interest in the applicant or licensee; or a person or entity that serves as an officer of, is on the board of directors of, or has a 5% or greater ownership interest in the management company or other entity, related or unrelated, with which the applicant or licensee contracts to manage the provider. The term does not include a voluntary board member.Note: For each controlling interest an AHCA screening through the Care Provider Background Screening Clearinghouse is needed or the Attestation of Compliance with Background Screening Requirements, AHCA Form 3100-0008 if background screening was conducted by the Department of Financial Services for an applicant for a certificate of authority to operate a continuing care retirement community under Chapter 651, F.S. To verify who is to be screened, visit . Individual and/or Entity Ownership of Management Company: Provide the information for each individual or entity (corporation, partnership, association) with 5% or greater ownership interest in the management company. Attach additional sheets if necessary.FULL NAME of INDIVIDUAL or ENTITYPRIMARY ADDRESSTELEPHONE NUMBEREIN(No SSN)% OWNERSHIPEFFECTIVE DATEEND DATE FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Board Members and Officers of Management Company: Provide the information for each individual or entity (corporation, partnership, association) that serves as an officer or is on the board of directors. Do not include voluntary board members.TITLEFULL NAMEPERSONAL/PRIMARY ADDRESSTELEPHONE NUMBEREFFECTIVE DATEEND DATEBoard Member/Officer FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Board Member/Officer FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Board Member/Officer FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Board Member/Officer FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????5. PersonnelPlease provide information for the individual(s) who perform the following roles. Note: For the administrator and financial officer an AHCA screening through the Care Provider Background Screening Clearinghouse is needed or the Attestation of Compliance with Background Screening Requirements, AHCA Form 3100-0008, if background screening was conducted by the Department of Financial Services for an applicant for a certificate of authority to operate a continuing care retirement community under Chapter 651, F.S. To verify who is to be screened, visit . INFORMATIONADMINISTRATOR/MANAGING EMPLOYEEFINANCIAL OFFICER / PERSON RESPONSIBLE FOR FINANCIAL OPERATIONSFull Name FORMTEXT ????? FORMTEXT ?????Date of Birth FORMTEXT ????? FORMTEXT ?????Effective Date FORMTEXT ????? FORMTEXT ?????End Date FORMTEXT ????? FORMTEXT ?????Telephone Number FORMTEXT ????? FORMTEXT ?????Email Address FORMTEXT ????? FORMTEXT ?????Personal/Primary Address FORMTEXT ????? FORMTEXT ?????Safety Liaison – Provide the requested information for the individual who will serve as primary contact during emergency operations pursuant to 408.821, F.RMATIONSAFETY LIAISONFull Name FORMTEXT ?????Date of Birth FORMTEXT ?????Effective Date FORMTEXT ?????End Date FORMTEXT ?????Telephone Number FORMTEXT ?????Email Address FORMTEXT ?????Personal/Primary Address FORMTEXT ?????6.Required DisclosureThe following disclosures are required:Pursuant to section 408.809, F.S., the applicant shall submit to the agency a description and explanation of any convictions of offenses prohibited by sections 435.04 and 408.809, F.S., for each controlling interest.Has the applicant or any individual listed in sections 3 and 4 of this application been convicted of any level 2 offense pursuant to section 408.809, F.S.? YES FORMCHECKBOX NO FORMCHECKBOX If YES, provide the following information: FORMCHECKBOX The full legal name of the individual and the position held FORMCHECKBOX A description/explanation of any convictionsPursuant to section 408.810(2), F.S., the applicant must provide a description and explanation of any exclusions, suspensions, or terminations from the Medicare, Medicaid, or federal Clinical Laboratory Improvement Amendment (CLIA) programs. Has the applicant or any individual/entity listed in sections 3 and 4 of this application been excluded, suspended, terminated or involuntarily withdrawn from participation in Medicare or Medicaid in any state?YES FORMCHECKBOX NO FORMCHECKBOX If YES, enclose the following information: FORMCHECKBOX The full legal name of the individual (and the position held) or the entity FORMCHECKBOX A description/explanation of the exclusion, suspension, termination or involuntary withdrawal.Pursuant to section 408.815(4), F.S., has the applicant or a controlling interest in the applicant, or any entity in which a controlling interest of the applicant was an owner or officer when the following actions occurred ever been:Convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a felony under Chapter 409, Chapter 817, Chapter 893, 21 U.S.C. ss. 801-970, or 42 U.S.C. ss. 1395-1396, Medicaid fraud, Medicare fraud, or insurance fraud, within the previous 15 years prior to the date of this application? YES FORMCHECKBOX NO FORMCHECKBOX Terminated for cause from the Medicare program or a state Medicaid program? YES FORMCHECKBOX NO FORMCHECKBOX If YES, has applicant been in good standing with the Medicare program or a state Medicaid program for the most recent 5years and the termination occurred at least 20 years before the date of the application. YES FORMCHECKBOX NO FORMCHECKBOX 7.Provider Fines and Financial InformationPursuant to subsection 408.831(1)(a), F.S., the Agency may take action against the applicant, licensee, or a licensee which shares a common controlling interest with the applicant if they have failed to pay all outstanding fines, liens, or overpayments assessed by final order of the agency or final order of the Centers for Medicare and Medicaid Services (CMS), not subject to further appeal, unless a repayment plan is approved by the agency.Are there any incidences of outstanding fines, liens or overpayments as described above? YES FORMCHECKBOX NO FORMCHECKBOX If YES, please complete the following for each incidence (attach additional sheets if necessary):AHCA CASE NUMBERCMSASSESSED AMOUNTDATE OF RELATED INSPECTION, APPLICATION, OR OVERPAYMENTPAYMENT DUE DATEPENDING APPEAL OF FINAL ORDERYESNO FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX Please attach a copy of the approved repayment plan if applicable.8.Federal CertificationDoes the provider participate in or intend to participate in theMedicaid program?YES FORMCHECKBOX NO FORMCHECKBOX Medicare program?YES FORMCHECKBOX NO FORMCHECKBOX If you plan to participate in Medicaid:Visit the Agency’s website at: in order to obtain information and an application for enrollment in Medicaid.If you plan to participate in Medicare: The Medicare Provider Application (CMS Form 855) is available from the Medicare Administrative Contractor or on the Centers for Medicare and Medicaid Services (CMS) website at: cms.cmsforms/. The form must be sent directly to the chosen Medicare Administrative Contractor for review. For initial Medicare enrollment, the following forms must be attached to the Medicare Application: FORMCHECKBOX CMS 1561 FORMCHECKBOX Medicare Administrative Contractor Choice Form FORMCHECKBOX Confirmation of submission of the Assurance of Compliance to the Office of Civil Rights9.Bed CapacityHOSPITAL BED UTILIZATIONCURRENT BED COUNTINCREASEDECREASEFINAL BED COUNTAcute Care FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Skilled Nursing Unit FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Comprehensive Medical Rehabilitation FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Adult Psychiatric FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Child Psychiatric FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Adult Substance Abuse FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Child Substance Abuse FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Level II Neonatal Intensive Care FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Level III Neonatal Intensive Care FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Intensive Residential Treatment Facility FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Long Term Care FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????TOTAL BED CAPACITY: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????10.General InformationPlease provide the following information:Classification:Class I HospitalClass III Specialty Hospital FORMCHECKBOX General Acute Care Hospital FORMCHECKBOX Specialty Medical Hospital FORMCHECKBOX Long Term Care Hospital FORMCHECKBOX Specialty Rehabilitation Hospital FORMCHECKBOX Rural Hospital ( FORMCHECKBOX Critical Access Hospital) FORMCHECKBOX Specialty Psychiatric Hospital FORMCHECKBOX Specialty Substance Abuse HospitalClass II Specialty HospitalClass IV Specialty Hospital FORMCHECKBOX Specialty Hospital for Children FORMCHECKBOX Intensive Residential Treatment Facility FORMCHECKBOX Specialty Hospital for WomenLicensed Programs:Attach the program specific application for initial designation. Attach the cardiac catheterization and cardiovascular services application with license renewal. FORMCHECKBOX Burn Unit - Verified FORMCHECKBOX Burn Unit - Provisional FORMCHECKBOX Acute Stroke Ready Center FORMCHECKBOX Adult Inpatient Diagnostic Cardiac Catheterization FORMCHECKBOX Primary Stroke Center FORMCHECKBOX Level I Adult Cardiovascular Services FORMCHECKBOX Comprehensive Stroke Center FORMCHECKBOX Level II Adult Cardiovascular Services11.AccreditationThe applicant participates in one of the accrediting organization below or FORMCHECKBOX Not accredited:ACCREDITING ORGANIZATIONACCREDITATION IDFEDERALLYDEEMEDEFFECTIVE DATEEXPIRATION DATESURVEYEND DATE FORMCHECKBOX AOA’s Bureau of Healthcare Facilities Accreditation FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX DNV GL Healthcare, Inc FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX The Joint Commission (JC) FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Commission on Accreditation of Rehabilitation Facilities - Class IV hospital only (CARF) FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Center of Improvement in Healthcare Qualify (CIHQ) FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Note: If accredited, provide a copy of the full accreditation survey, award letter and any follow up letters to or from the accrediting body. Please review chapter 119, F.S. for additional information. FORMCHECKBOX I understand that the complete accreditation report must be submitted to the Agency for review if the accreditation report is to be accepted in lieu of annual licensure inspections and such reports used to meet licensure requirements are considered public documents subject to disclosure per chapter 119, F.S. A complete accreditation report includes correspondence from the accrediting organization containing the dates of the survey, any citations to which the accreditation organization requires a response the facility’s response to each citation, the effective date of accreditation and verification of Medicare (CMS) deemed status, if applicable.12.Clinical Laboratory ServicesPursuant to section 395.009 and 395.0091, F.S. minimum standards are required for clinical laboratory test results and diagnostic X-ray results as a prerequisite for issuance or renewal of license. Please indicate which of the following apply. FORMCHECKBOX 1. Minimum standards are established for acceptance of results of diagnostic X rays performed by or for the hospital. These standards require licensure or registration of the source of ionizing radiation under the provisions of chapter 404. FORMCHECKBOX 2. All clinical laboratory tests performed by or for the hospital are performed by a clinical laboratory appropriately certified by the Centers for Medicare and Medicaid Services under the federal Clinical Laboratory Improvement Amendments and the federal rules adopted thereunder. FORMCHECKBOX a. Alternate-site testing is performed within the hospital premises. The tests performed at each location are listedon the attached AHCA Form 3130-8013. FORMCHECKBOX b. Alternate-site testing is not performed within the hospital premises.13.Additional AddressesNON-EMERGENCY, NON-SURGICAL OFFSITE OUTPATIENT FACILITY. Provide the following information regarding offsite outpatient facilities, including urgent care centers, owned and operated by the hospital. For new locations, attach proof of ownership/right to occupy and approval from the Agency’s Bureau of Plans and Construction. Attach additional sheets if necessary.NAMESTREET ADDRESS FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????NON-EMERGENCY SURGICAL OFFSITE OUTPATIENT FACILITY. Provide the following information regarding non-emergency offsite outpatient facilities owned and operated by the hospital providing surgical treatments requiring general anesthesia or IV conscious sedation or cardiac catheterization services. For new locations, attach proof of ownership/right to occupy and approval from the Agency’s Bureau of Plans and Construction. Attach additional sheets if necessary.NAMESTREET ADDRESS FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????OFFSITE EMERGENCY DEPARTMENT. Provide the following information regarding offsite emergency departments. Emergency services offered offsite must be available 24 hours per day, 7 days per week offering the same services as the emergency department located on the hospital premises. In addition, please complete section 13 Hospital Emergency Services of this application. Attach additional sheets if necessary.NAMESTREET ADDRESS FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????14.Hospital Emergency ServicesPlease indicate the emergency services provided. Mark the appropriate box for each service. FORMCHECKBOX Emergency services are offered via an emergency department located within the hospital and/or off site if indicated in section 11C of this application. FORMCHECKBOX Hospital has an Emergency 2 Way Radio System pursuant to section 395.1031, F.S. FORMCHECKBOX Request for emergency service exemption per section 395.1041(3)(d)3, F.S., attach AHCA Form 3000-1, if applicable. FORMCHECKBOX Baker Act Receiving Facility designation from the Department of Children and Families, attach certificate, if applicable. FORMCHECKBOX Trauma Center designation issued from the Department of Health, Office of Trauma, if applicable. Indicate level: FORMCHECKBOX PROVISIONAL LEVEL 1 FORMCHECKBOX PROVISIONAL LEVEL 2 FORMCHECKBOX PROVISIONAL PEDIATRIC FORMCHECKBOX LEVEL 1 FORMCHECKBOX LEVEL 2 FORMCHECKBOX PEDIATRIC FORMCHECKBOX No dedicated emergency department. Mark the below boxes as appropriate.SERVICENOT PROVIDEDPROVIDED ON SITE 24 HOURS PER DAY, 7 DAYS PER WEEKPROVIDED THROUGH A COMBINATION OF ONSITE AND TRANSFER AGREEMENT(S) WITH ANOTHER HOSPITAL(S) 24 HOURS PER DAY, 7 DAYS PER WEEKPROVIDED THROUGH TRANSFER AGREEMENT WITH ANOTHER HOSPITAL(S)PROVIDED ON A LIMITED BASIS BY EXEMPTION OR PARTIAL EXEMPTIONAnesthesia FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Burns FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Cardiology FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Cardiovascular Surgery FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Colon/Rectal Surgery FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Emergency Medicine FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Endocrinology FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Gastroenterology FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX General Surgery FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Gynecology FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Hematology FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Hyperbaric Medicine FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Internal Medicine FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Nephrology FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Neurology FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Neurosurgery FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Obstetrics FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Ophthalmology FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Oral/Maxillofacial Surgery FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Orthopedics FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Otolaryngology FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Plastic Surgery FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Podiatry FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Psychiatry FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Pulmonary Medicine FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Radiology FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Thoracic Surgery FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Urology FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Vascular Surgery FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 15.Florida Patient’s Compensation Trust FundAUTHORITY: Pursuant to subsection 766.105(2)(d)2. F.S., “Annually the Agency for Health Care Administration shall require documentation by each hospital that such hospital is in compliance, and will remain in compliance; with the provisions of this section … The agency may not issue or renew the license of any hospital which has not been certified by the board of governors. The license of any hospital that fails to remain in compliance or fails to provide such documentation shall be revoked or suspended by the Agency.” Please complete the applicable section of this form and return it with the appropriate documentation. Please be advised – a policy binder is not sufficient proof of coverage.The hospital named in this application is exempt from participation in the Florida Patient’s Compensation Fund for the current calendar year, because it has demonstrated its current financial responsibility and certifies it will maintain such financial responsibility to pay claims and costs arising out of the rendering of, or the failure to render, medical care or services and for bodily injury or property damage to the person or property of any patient arising out of their activities for this period by: FORMCHECKBOX A bond posted in the amount equivalent to $10,000 per claim for each hospital bed, not to exceed a $2,500,000 annual aggregate. FORMCHECKBOX An escrow account in an amount equivalent to $10,000 per claim for each hospital bed, not to exceed a $2,500,000 annual aggregate to the satisfaction of the Agency for Health Care Administration. FORMCHECKBOX Professional liability coverage in an amount equivalent to $10,000 or more per claim for each hospital bed, from a private insurer, the Joint Underwriting Association; or through a plan of self-insurance as provided in section 627.357, F.S., not to exceed a $2,500,000 annual aggregate. Include proof of funding any self-insurance retention. FORMCHECKBOX Sovereign immunity. State Agencies, subdivisions or instrumentalities of the state. No additional documentation necessary if previously documented.16.Supporting DocumentsApplicants must include the following attachments as stated in Chapter 408, Part II and Chapter 395, F.S. and Chapters 59A-35 and 58A-3 F.A.C. Note: Required documents listed below are dependent on the type of application submitted. (Initial, Renewal, Change of Ownership, Change During Licensure Period)DOCUMENTS TO BE PROVIDED:REQUIRED FOR: Proof of the most recent accreditation report, if applicableInitial, Renewal and Change of Ownership application typesHealth Care Licensing Application Addendum, AHCA Form 3110-1024Initial, Renewal and Change of Ownership application typesDocumentation signed by the appropriate local government official, which states that the applicant has met local zoning requirementsInitial, Addition of Offsite Emergency Department, and Address Change application typesProof of legal right to occupy property may include but not limited to, copies of warranty deeds, lease or rental agreements, contracts for deeds, quitclaim deeds, or other such documentationInitial, Change of Ownership and Change of Address application typesCopy of Certificate of Need issued by Agency for Health Care Administration Initial, and Bed Change application typesAdult Inpatient Diagnostic Cardiac Catheterization application, AHCA Form 3130-5003, if applicableAddition of Licensed Program application typesLevel I Adult Cardiovascular Services application, AHCA Form 3130-8010, if applicableRenewal and Addition of Licensed Program application typesLevel II Adult Cardiovascular Services application, AHCA Form 3130-8011, if applicableRenewal and Addition of Licensed Program application typesStroke Center Affidavit, AHCA Form 3130-8009, if applicableAddition of Licensed Program applicationBurn Unit Services, AHCA Form 3130-8012, if applicableAddition of Licensed Program applicationBaker Act Receiving Facility certificate, if applicable.Initial and Addition of Licensed ProgramEmergency Service Exemption Application, AHCA Form 3000-1, if applicableR and Request for Emergency Service Exemption application typeDocumentation of compliance with the Florida Patient Compensation Trust FundInitial, Renewal, Change of Ownership and Change application typesLicense Application Alternate – Site Testing, AHCA Form 3130-8013All application types, if applicableApproval by the Agency’s Bureau of Plans & Construction Initial, Bed Change and Addition of Offsite Emergency Department application typesDocumentation of change of ownership transaction stating effective date and executed by all parties.Change of Ownership application typeRequired disclosures related to actions taken by Medicare, Medicaid or CLIA, if applicableAll application typesApproved repayment plan, if applicableAll application types17.AttestationI, ______________________________, attest as follows: Pursuant to section 837.06, Florida Statutes, I have not knowingly made a false statement with the intent to mislead the Agency in the performance of its official duty. Pursuant to section 408.815, Florida Statutes, I acknowledge that false representation of a material fact in the license application or omission of any material fact from the license application by a controlling interest may be used by the Agency for denying and revoking a license or change of ownership application. Pursuant to section 408.806, Florida Statutes, under penalty of perjury, the applicant is in compliance with the provisions of section 408.806 and Chapter 435, Florida Statutes. Pursuant to sections 408.809 and 435.05, Florida Statutes, every employee of the applicant required to be screened has attested, subject to penalty of perjury, to meeting the requirements for qualifying for employment pursuant to Chapter 408, Part II, and Chapter 435, Florida Statutes, and has agreed to inform the employer immediately if arrested for any of the disqualifying offenses while employed by the employer.Pursuant to section 435.05, Florida Statutes, the applicant has conducted a level 2 background screening through the Agency on every employee required to be screened under Chapter 408, Part II, or Chapter 435, Florida Statutes, as a condition of employment and continued employment and that every such employee has satisfied the level 2 background screening standards or obtained an exemption from disqualification from employment. FORMCHECKBOX This hospital offers birthing services and is in compliance with subsection 382.013(2)(c), Florida Statutes regarding assistance to unmarried parents who wish to execute a voluntary acknowledgement of paternity. FORMCHECKBOX This hospital does not offer birthing services and subsection 395.003(5)(c), Florida Statutes is not applicable to this application.Signature of Licensee or Authorized RepresentativeTitleDateNOTICE: If you are a Medicaid provider, you may have a separate obligation to notify the Medicaid program of a name/address change, change of ownership or other change of information. Please refer to your Medicaid handbooks for additional information about Medicaid program policy regarding changes to provider enrollment information.left19050RETURN THIS COMPLETED FORM WITH FEES TO:AGENCY FOR HEALTH CARE ADMINISTRATION HOSPITAL AND OUTPATIENT SERVICES UNIT2727 MAHAN DR., MS 31TALLAHASSEE FL 32308-5407Questions? Visit the Agency’s website?: or contact the Hospital and Outpatient Services Unit at (850) 412-4549 or Email: hospitals@ahca.00RETURN THIS COMPLETED FORM WITH FEES TO:AGENCY FOR HEALTH CARE ADMINISTRATION HOSPITAL AND OUTPATIENT SERVICES UNIT2727 MAHAN DR., MS 31TALLAHASSEE FL 32308-5407Questions? Visit the Agency’s website?: or contact the Hospital and Outpatient Services Unit at (850) 412-4549 or Email: hospitals@ahca.left105907The 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 applicationInclude license number or case number on your checkDo not submit carbon copies of documentsDo not fold any of the documents being submittedNo staples, paperclips, binder clips, folders, or notebooks Please do not bind any of the documents submitted to the Agency.00The 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 applicationInclude license number or case number on your checkDo not submit carbon copies of documentsDo not fold any of the documents being submittedNo staples, paperclips, binder clips, folders, or notebooks Please do not bind any of the documents submitted to the Agency. ................
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