FL Agency for Health Care Administration



952513335000262890032386APPLICATION CHECKLISTHOME HEALTH AGENCY00APPLICATION CHECKLISTHOME HEALTH AGENCY*PLEASE NOTE - THE AGENCY ENCOURAGES ALL APPLICANTS TO USE THIS SERVICE*The Agency for Health Care Administration (AHCA) has implemented its new ONLINE LICENSING SYSTEM which allows electronic submission of renewal applications and fees, along with the ability to upload supporting documentation. To renew online please go to: 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/certificationRenewal (R) – biennial renewal of existing license/registration/certificationChange of Ownership (CHOW) – change of 51% or more of the ownership OR licensee sells/transfers ownership to a different individual/entityChange during Licensure Period (CL) – request to amend /change information that displays on the licenseName 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 not display 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) FORMCHECKBOX 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) FORMCHECKBOX 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 CorporationsContact Person (Application Types: All) FORMCHECKBOX Name, email address, telephone number, and fax numberLicensee Controlling Interests, Board Members, and Officers (Application Types: I, R, CHOW, CNL/ST) FORMCHECKBOX 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 officerManagement Company, (if applicable) (Application Types: I, R, CHOW, CNL/ST) FORMCHECKBOX Name, EIN, street address, mailing address, email address, telephone number, and fax numberManagement Company Controlling Interests, Board Members, and Officer (Application Types: I, R, CHOW, CNL/ST) FORMCHECKBOX 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 officerPersonnel (Application Types: I, R, CHOW, CNL/P if applicable) FORMCHECKBOX Name, SSN, date of birth, personal mailing address, email address, telephone number, fax number, Florida healthcare license number (if applicable) and effective date of employmentRequired Disclosure (Application Types: I, R, CHOW) FORMCHECKBOX Legal information (if any) for licensee, licensee controlling interests, management company, and management company controlling interestsProvider Fines and Financial Information (Application Types: I, R, CHOW) FORMCHECKBOX 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) FORMCHECKBOX Patient census, skilled services to children, non-skilled services and number of direct and contracted employees including name of contracted agency if applicableGeographic Service Area (Application Types: I, R, CHOW, CL/AC if applicable) FORMCHECKBOX Counties servedOther Associated Locations (Application Types: I, R, CHOW, CL/ASOA if applicable)) FORMCHECKBOX Satellite Office street address, city zip, county, telephone number FORMCHECKBOX Drop-Off Site street address, city zip, countyDays and Hours of Operation (Application Types: I, R, CHOW, CNL/OP if applicable)) FORMCHECKBOX Days of the week, opening time and closing timeAccreditation/Deemed Status (Application Types: I, R, CHOW) FORMCHECKBOX Accreditation information including name of accrediting organization, effective and expiration dates of accreditationSupporting Documents (Application Types: All, unless otherwise specified) FORMCHECKBOX Proof of current general liabilityand malpractice insurance coverage - (Application Types: All) FORMCHECKBOX Surety or continuation bond - (Application Types: All – for applicants that check YES on section 6.D. on the home health agency application only) FORMCHECKBOX Proof of current accreditation - documentation and survey report - (Application Types: I, R, CHOW, CL/A ) FORMCHECKBOX 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) FORMCHECKBOX 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) FORMCHECKBOX Facility ownership/lease documentation (if applicable) (Application Types: I, CHOW, CL/A) FORMCHECKBOX Documentation signed by the appropriate local government official, which states that the applicant has met local zoning requirements - (Application Types: I, CHOW, CL/A) FORMCHECKBOX 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) FORMCHECKBOX Documentation of change of ownership transaction stating effective date and executed by all parties - (Application Types: CHOW, CNL/ST) FORMCHECKBOX Health Care Licensing Application Addendum, AHCA Form 3110-1024 - (Application Types: I, R, CHOW) FORMCHECKBOX Fire safety inspection report - (Application Types: I, CHOW, CL/A FORMCHECKBOX Attestation of compliance with background screening requirements?if 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) FORMCHECKBOX Copy of exemption from disqualification for documented offenses (if applicable) – (Application Types: All) FORMCHECKBOX 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) FORMCHECKBOX Approved repayment plan (if applicable)Attestation (Application Types: All) FORMCHECKBOX Licensee or authorized representative Biennial Licensure Fee and Other Amounts Due Upon Submission of Application FORMCHECKBOX The biennial licensure fee is $1,705. FORMCHECKBOX 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) FORMCHECKBOX The replacement license certificate fee is $25. FORMCHECKBOX Other amounts due (fines, assessment, fees, etc.) will be detailed in the applicationThe 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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