*Please Note - the Agency Encourages All Applicants to Use This Service*
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APPLICATION REQUIREMENTS Health Care Licensing Application ASSISTED LIVING FACILITIES
*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 allowing providers the opportunity to renew their license online. The new online system allows for the electronic submission of renewal applications along with the ability to upload supporting documentation. Additionally, the system will save time and reduce errors by pre populating data fields and allow for the electronic payment of fees, fines and assessments. To renew online please go to: http://ahca.myflorida.com/onlinelicensure
All forms listed below may be obtained from the website: http://ahca.myflorida.com/ HQALicensureForms Send completed applications to: Agency for Health Care Administration, Assisted Living Unit, 2727 Mahan Drive, Mail Stop 30, Tallahassee, FL 32308. NOTE: Applications will not be considered for review until payment has been received.
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 (C) – request to amend /change information that displays on the license
In order to provide the Agency with a complete application and expedite the licensure process, you will need 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)
Contact Person (Application Types: All)
Name, email address, telephone number, and fax number
Administrator (Application Types: All)
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
Financial Officer (Application Types: All)
Name, SSN, date of birth, personal mailing address, email address, telephone number, fax number, and Florida healthcare license number (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 Corporation
Licensee Controlling Interests, Board Members, and Officers (Application Types: All)
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: All)
Name, EIN, street address, mailing address, email address, telephone number, and fax number
Management Company Controlling Interests, Board Members, and Officer (Application Types: All)
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
Required Disclosures (Application Types: All)
Legal information (if any) for licensee, licensee controlling interests, management company, and management company controlling interests
Provider Fines and Financial Information (Application Types: All)
Dollar amounts, assessing entities, case numbers, dates of assessment, final orders, repayment plans, next payment due dates of any monies owed to the Agency (AHCA) or the Centers for Medicare and Medicaid Services (CMS)
Financial Ability to Operate – (Application Types: I and CHOW)
Evidence of sufficient funds to operate such as bank statements, net worth statements or financial reports. Please submit this information using the Proof of Financial Ability to Operate form, AHCA Form 3100-0009
Bed Counts (Application Types: All)
Bed type information
Supporting Documents (Application Types: All, unless otherwise specified)
Proof of current general liability insurance coverage - (Application Types: All) Fire safety inspection report - (Application Types: All) Department of Health group care inspection report - (Application Types: All) Department of Health food service inspection report/ Food Permit - (Application Types: All – for providers with 11 beds or more only) Surety or continuation bond - (Application Types: All – for applicants that check YES on section 8.A on the assisted living recommended application only) Local zoning form - (Application Types: I, C and CHOW) Community residential home affidavit of compliance - (Application Types: I, C and CHOW) Septic system or water supply evaluation report - (Application Types: I and C) Copy of Administrator’s high school diploma or GED certificate - (Application Types: I, CHOW or new administrator added upon renewal) Affidavit 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) Facility ownership/lease documentation (if applicable) Copy of exemption from disqualification for documented offenses (if applicable) Approved repayment plan (if applicable)
Biennial Licensure Fee and Other Amounts Due
The biennial licensure fee is $387.73 plus $64.96 per private pay bed fee The extended congregate care fee is $546.07 plus $10.15 per bed fee The limited nursing service fee is $322.77 plus $10.15 per bed fee 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) Other amounts due (fines, assessment, fees, etc.) will be detailed in the application
Notice: 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.
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.