Application Homemaker Companion Recommend by vdfwuy4

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									                                                       APPLICATION CHECKLIST
                                                       HOMEMAKER COMPANION SERVICES
                                                              REGISTRATION

This application is for organizations that provide homemaker and/or companion services, as required
in the state law, section 400.509, Florida Statutes.

An individual who works alone and does not hire or arrange for others to provide homemaker and/or
companion services can work on their own without registration and should not apply.



A. Initial, Renewal and Change of Ownership applications must include:

1.      The $50.00 registration fee - Please make check or money order payable to the
        Agency for Health Care Administration (AHCA). All fees are nonrefundable. NOTE: Starter
        checks and temporary checks are not accepted.


2.      Homemaker Companion Services Registration Application, (AHCA Form
        3110-1003). Do not include social security numbers on this form. All social security
        numbers must be entered on the Addendum attached to this application.

3.      Submit copies of brochures, flyers or other print advertising.

4.      A Level 2 Background Screening must be conducted every 5 years for the Managing
        Employee and the Financial Officer. Please check the box below to indicate the process
        you used to conduct screening.
            The     Managing Employee and/or       Financial Officer submitted a Level 2 screening
        through a LiveScan vendor approved to submit fingerprint requests through the Florida
        Department of Law Enforcement (FDLE). For more information regarding LiveScan vendors
        please see the Agency’s background screening website at:
        http://ahca.myflorida.com/MCHQ/Long_Term_Care/Background_Screening/index.shtml.


        All screening results must be sent to the Agency for Health Care Administration (Agency)
        for review and eligibility determinations. If you choose to use a LiveScan source other than the
        Agency’s contracted vendor you must provide the following ORI FL922020Z and identify the
        Agency for Health Care Administration as the recipient of the screening results to ensure the
        results are reviewed by the Agency. If the Agency does not receive the result, additional
        screening and fees may be required.
        The Agency has created a form that you may use to take to the vendor. You may access this
        form, Background Screening Validation, on the Agency’s website at:
        http://ahca.myflorida.com/MCHQ/Long_Term_Care/Background_Screening/index.shtml.



AHCA Recommended Form 3110-1003, Revised August 2011                               Section 59A-35.060(1), Florida Administrative Code
INSTRUCTION CHECKLIST                                     Form available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml
         The    Managing Employee and/or           Financial Officer are out of state and do not have
        access to a Florida LiveScan vendor and will submit a fingerprint card (you must obtain a
        fingerprint card from the Agency. To request a fingerprint card please contact the Agency’s
        Background Screening Section at (850)412-4503 or email bgscreen@ahca.myflorida.com.).
        The fingerprint card must be submitted to:

                The Agency’s contracted vendor, Cogent Systems, along with a fee of $58.25 ($43.25
                for the screening + $15.00 processing fee). The fingerprint card must be filled out
                completely and the fingerprints taken by law enforcement personnel or individual trained
                in processing fingerprints. Return the completed card to:
                Cogent Systems
                Attn: Fingerprint Card Scan Florida
                5025 Bradenton Ave Suite A
                Dublin, OH 43017

                Another LiveScan vendor authorized to provide services in Florida that is equipped to
                transmit the images of the fingerprints from the fingerprint card electronically. This
                requires special equipment and not all LiveScan vendors have this ability. You may find
                LiveScan vendor contact information on the FDLE website:
                http://www.fdle.state.fl.us/Content/getdoc/04833e12-3fc6-4c03-9993-
                379244e0da50/livescan.aspx.

         I have proof of Level 2 screening within the previous 5 years for the         Managing Employee
         and/or        Financial Officer from the Agency, the Department of Children and Families,
         Department of Health, Agency for Persons with Disabilities or Department of Financial
         Services (if the applicant has a certificate of authority to operate a continuing care retirement
         community) is included with this application. An Affidavit of Compliance with Background
         Screening Requirements, AHCA Form 3100-0008, is also enclosed.




All forms can be obtained from the website at
http://ahca.myflorida.com/Publications/Forms/HQA.shtml click on “Homemaker Companion.”

RETURN FORMS + FEE(s) TO:
Agency for Health Care Administration, Home Care Unit, 2727 Mahan Drive, Mail Stop #34,
Tallahassee, FL 32308




IMPORTANT NOTE FOR RENEWALS:
Applications must be received at the address above at least 60 days in advance of expiration of
registration to avoid a late fine.

IMPORTANT NOTE FOR CHANGE OF ADDRESS, ADDITION OF COUNTIES OR CHANGE OF
NAME: A fee of $25.00 will be charged for a replacement license or any business name


AHCA Recommended Form 3110-1003, Revised August 2011                            Section 59A-35.060(1), Florida Administrative Code
INSTRUCTION CHECKLIST                                  Form available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml
change, change of address or addition of counties served that occurs before the expiration of
the license.


IMPORTANT NOTE FOR CHANGES OF OWNERSHIP: The registration may not be sold, assigned
or otherwise transferred per state law (408.804(2), Florida Statutes). Thus, an application must be
submitted for a new registration. Applications must be received from the buyer (transferee) at the
address above at least 60 days prior to the actual change of ownership of the business. It must
include a letter signed by the seller (transferor) notifying AHCA of the coming sale or transfer to the
buyer per 408.807, F.S.



NOTE: If you have additional questions after reviewing the application forms, Frequently Asked
Questions, and Florida Statutes at the AHCA web site (address above), please call the Home Care
Unit at (850) 414-6010. Staff will be happy to answer questions, but cannot walk you through the
application forms. Filling out the forms is part of your responsibility as an applicant. The Agency's
role in this process is to evaluate your application and, if there are items missing from your application
once received, send you a letter that gives you another chance to complete the application
successfully. If you need help in filling out the application forms, we would advise you to seek help
from an attorney or a consultant.




The Agency for Health Care Administration scans all documents for electronic storage. In an effort to facilitate this process, we ask that
you please place checks, money orders and fingerprint cards on top of the application and paperclip everything together.
Please do not staple or bind documents submitted to the Agency.




AHCA Recommended Form 3110-1003, Revised August 2011                                          Section 59A-35.060(1), Florida Administrative Code
INSTRUCTION CHECKLIST                                                Form available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml
                                                                                          AHCA USE ONLY:
                                                                                          File #:
                                                                                          Application #:
                                                                                          Check #:
                                                                                          Check Amt:
                                                                                          Batch #:




                           HOMEMAKER COMPANION SERVICES REGISTRATION
This application is for organizations that provide homemaker and/or companion services, as required
in the state law, section 400.509, Florida Statutes. An individual who works alone and does not hire
or arrange for others to provide homemaker and/or companion services can work on their own
without registration and should not apply.

1. Business Identification

Name of Homemaker Companion Service (name your business will use)

Is this name a fictitious (doing business as) name?           YES            NO
If YES, the fictitious name must be registered with the Department of State, Division of Corporations. For more
information go to www.sunbiz.org or call (850)245-6058.
Street Address (physical location of business)

City                                                      County                               State        Zip
                                                                                               Florida
Telephone Number                      Fax Number          E-mail Address                          Provider Website


Mailing Address or        Same as above (all mail will be sent to this address)

City                                                        State                      Zip

Contact Person for this application                                       Contact Telephone Number

Contact e-mail address or          Do not have e-mail           NOTE: By providing your e-mail address you agree
                                                                to accept e-mail correspondence from the Agency
Please include copies of brochures, flyers or other print advertising with this application.


2.      Fees Required with Application
Indicate the type of application with an “X.” Applications will not be processed if all applicable
fees are not included. All fees are nonrefundable.


       Initial Registration Renewal Registration – Registration #                                                              $50.00
       Change of Ownership – Registration # of business being purchased
       Business name change, change of address, addition of counties, replacement license                                      $25.00
                                                                      TOTAL AMOUNT ENCLOSED $
                                                (Send check or money order made payable to AHCA)

AHCA Recommended Form 3110-1003, Revised August 2011                                   Section 59A-35.060(1), Florida Administrative Code
Page 1 of 6                                                  Form available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml
                                                         NOTE: Starter checks and temporary checks are not accepted.




3.      Ownership (corporation, individual, etc. that directly owns this business)

Name or       Same as Section 1                                    Federal Employer Identification Number (EIN)
                                                                   (Do not enter your Social Security number)

Mailing Address or Same as Section 1

City                                                                                           State             Zip

Telephone or         Same as           Fax or    Same as           E-mail Address or             Same as Section 1
Section 1                              Section 1

Description of Licensee (check one):
        For Profit                                Not for Profit                              Public
           Corporation                               Corporation                                State
           Limited Liability Company                 Religious Affiliation                      City/County
           Partnership                               Limited Liability Company                Hospital District
           Sole Proprietor                           Other
           Other




4.     Ownership of Licensee


If For-Profit: List each individual and entity (corporation, partnership, etc.) with 5% or greater
financial interest in licensee. Attach additional sheets if needed.


If Not-For-Profit: Is the owning entity same as listed in Section 3?                        YES             NO         If yes, skip
this item. If no, please complete the following


                                 PERSONAL OR BUSINESS                   TELEPHONE                     EIN              % OWNERSHIP
    FULL NAME of
                                       ADDRESS                           NUMBER                    (No SSNs)             INTEREST
INDIVIDUAL or ENTITY




AHCA Recommended Form 3110-1003, Revised August 2011                                   Section 59A-35.060(1), Florida Administrative Code
Page 2 of 6                                                  Form available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml
5. Officers and Board Members of Licensee

List each person that serves as an officer or is on the board of directors. Attach additional
sheets if needed. A sole proprietor is the president of the corporation.



     TITLE                                    FULL NAME
                                                                                                TELEPHONE NUMBER
President
Vice
President
Secretary
Treasurer
Board
Member
Board
Member
Board
Member
Board
Member
Board
Member



6.    Convictions


Have any of the persons listed in sections 4 or 5 of this application been convicted of any
criminal offense listed in section 435.04 or 408.809(5), Florida Statutes? (The Florida Statutes
can be viewed at http://www.leg.state.fl.us/Statutes/ or at your local library. In addition, these
offenses are listed on the Affidavit of Compliance with Background Screening Requirements, AHCA
Form #3100-0008, Nov. 2006.)              YES           NO


If yes, enclose the following information:

     The full legal name of the individual and the position held

     An explanation of the conviction(s) - If the individual has received an exemption from
     disqualification for the offense, include a copy.




AHCA Recommended Form 3110-1003, Revised August 2011                                Section 59A-35.060(1), Florida Administrative Code
Page 3 of 6                                               Form available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml
7.    Terminations, Exclusions, Suspensions or Involuntary Withdrawals

        The following disclosures are required:
A.    Pursuant to section 408.810(2), F.S., the applicant must provide a description and explanation of
      any exclusions, suspensions, or terminations of the applicant from the Medicare, Medicaid, or
      federal Clinical Laboratory Improvement Amendment (CLIA) programs.
      Has the applicant or any individual 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                    NO
                If yes, enclose the following information:
                The full legal name of the individual and the position held
                A description/explanation of the exclusion, suspension, termination or involuntary
                withdrawal.


B. Pursuant to section 408.815(4), F.S., does the applicant or any controlling interest in an applicant
   have any of the following:

     YES           NO            Convicted of, or enters a plea of guilty or nolo contendere to, regardless of
                                 adjudication, a felony under chapter 409, chapter 817, chapter 893.21,
                                 Florida Statute, U.S.C. ss. 801-970, or 42 U.S.C. ss. 1395-1396, within the
                                 previous 15 prior to the date of the application;

     YES           NO            Terminated for cause from the Florida Medicaid program pursuant to s.
                                 409.913, and have not been in good standing with the Florida Medicaid
                                 program for the most recent 5 years;

     YES           NO            Terminated for cause, pursuant to the appeals procedures established by
                                 the state or Federal Government, from the federal Medicare program or
                                 from any other state Medicaid program, have not been in good standing
                                 with a state Medicaid program or the federal Medicare program for the
                                 most recent 5 years and the termination was less than 20 years prior to
                                 the date of the application.



8.    Interest in Other Health Care Providers

Does this business (Section 1), its ownership (Section 3) or any persons listed in Section 4 of this
application have 5% or more financial interest or serve as an officer or board member of any other
registered or licensed health care provider?    YES           NO


AHCA Recommended Form 3110-1003, Revised August 2011                               Section 59A-35.060(1), Florida Administrative Code
Page 4 of 6                                              Form available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml
If yes, provide the following information:

                                         LICENSE TYPE
         PROVIDER NAME                   AND NUMBER                     STREET ADDRESS                                   EIN #




9.    Counties Served

List each county this business location will serve:
NOTE: This registration covers only one office location. Each additional office must be separately
registered.
1.                                                             8.
2.                                                             9.
3.                                                             10.
4.                                                             11.
5.                                                             12.
6.                                                             13.
7.                                                             14.




10. Personnel
Please list all persons who manage this business:
       FULL LEGAL NAME                        TITLE                         ADDRESS                               DATE OF BIRTH
                                        Managing Employee

                                          Financial Officer




AHCA Recommended Form 3110-1003, Revised August 2011                                    Section 59A-35.060(1), Florida Administrative Code
Page 5 of 6                                                   Form available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml
11. AFFIDAVIT
I hereby swear, under penalty of perjury, that the statements in this application, the statements below and the forms and
documents enclosed with this application are true and correct. I understand that providing false information or omitting
required information in this application may result in denial of this application.

     A. I will comply with the state laws for homemaker companion services in Chapter 400, Part III, and Chapter 408,
        Part II, Florida Statutes.

    B. All personnel employed or contracted with have had a criminal history check through the Florida Department of
       Law Enforcement, the Agency for Health Care Administration, or the Department of Children and Families as
       required in state law, section 400.512 and Chapter 435, Florida Statutes.
                            st
    C. On or before the 1 day of service, every client will receive the 2 toll-free telephone numbers in a statement that
       says:

       1. Complaints. "To report a complaint regarding the services you receive or to report suspected Medicaid fraud,
           please call toll-free 1-888 419-3456."

       2. Abusive, neglectful, or exploitative practices. "To report abuse, neglect, or exploitation, please call toll-free 1-
         800-962-2873."

    D. The registration number issued by AHCA to this business will be included in all advertisements.

    E. I understand homemaker and companion services cannot provide any hands-on personal care to clients receiving
       homemaker and/or companion services per state law (400.462(7) & (15), Florida Statutes). However, there is
       one exception: If your business has had, since prior to January 1, 1999, both this registration + authorization to
       provide personal care under a Developmental Services provider certificate, please check this box:       .




  Signature of Owner or Authorized Representative           Title                                            Date




RETURN THIS COMPLETED FORM WITH FEES TO:
AHCA HOME CARE UNIT, 2727 MAHAN DRIVE - MS 34, TALLAHASSEE FL 32308-5407

Questions? See Frequently Asked Questions at http://ahca.myflorida.com/licensing_cert.shtml, click on “homemaker
companion” or (850) 412-4403.




AHCA Recommended Form 3110-1003, Revised August 2011                                      Section 59A-35.060(1), Florida Administrative Code
Page 6 of 6                                                     Form available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml
                                                        ADDENDUM TO APPLICATION FOR
                                                     HOMEMAKER COMPANION SERVICES
                                                            REGISTRATION




                                                  CONFIDENTIAL
For all persons listed in items 3, 4, 5, and 10 of this application, please provide the following:
(required in Section 408.806(1), Florida Statutes)

                               FULL NAME                                        SOCIAL SECURITY
                                                                                    NUMBER




This Addendum will not be included in the public record maintained for this homemaker companion service by
the Agency for Health Care Administration. It will be kept confidential.




AHCA Form 3110-1003, Addendum Revised July 2009                                  Section 59A-35.060(1), Florida Administrative Code
Page 1 of 1                                             Form available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml

								
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