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APPLICATIONpitoCHECKLIST
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Applicants must include the following attachments as stated in Chapters 408, Part II, and 400, Part IV, Florida Statutes (F.S.), and
Chapter 58A-2, Florida Administrative Code (F.A.C.). Applications must be received at least 60 days prior to the e xpiration of the
current license or effective date of a change of ownership to avoid a late fine. The application will be withdrawn from review if all
the required documents and fees are not included with this application or received within 21 days of an omission notice.
All forms listed below may be obtained from the website: http://ahca.myflorida.com/. Send completed applications to: Agency for
Health Care Administration, Home Care Unit, 2727 Mahan Drive, MS 34, Tallahassee, FL 32308-5407.
A. Initials, Renewals and Change of Ownership Applications must include:
NOTE TO ALL APPLICANTS: The Agency w ill verify that all applicants, licensees and controlling interests subject to Chapters 607, 608 or 617, Florida
Statutes related to Business Organiz ations have complied w ith applicable Department of State registration and filing requirements. The principal and
mailing addresses submitted w ith any application must be the same as the addresses that appear as registered with the Department of State, Division of
Corporations.
The biennial licensure fee ($1,200.00 per license) - Please make check or money order payable to the Agency for Health
Care Administration (AHCA). All fees are nonrefundable.
Health Care Licensing Application, Hospice, AHCA Recommended Form, February 2009 (8 pages)
Health Care Licensing Application Addendum , AHCA Recommended Form (3 pages)- Complete all information that is applicable,
write “NA” on the items that are not applicable, notarize and send with the application .
Affidavit of Compliance with Level 2 Background Screening for Covered Employees , AHCA Form 3100-0007, Nov 2006 (1 page),
as required by section 435.05(3), F.S. - This form must be submitted annually and is due within 1 year from the signature date of
the previous form on file.
A fingerprint card for a Level 2 background screening for the Administrator and Chief Financial Officer is required every 5 years.
Please check all boxes below that apply to this application:
A fingerprint card for a Level 2 background screening was submitted through the Agency’s Background Screening Unit within
the previous 5 years for the Administrator and/or Chief Financial Officer.
A fingerprint card for the Administrator and/or Chief Financial Officer is included with this application along with
the screening fee of $43.25 per screening. Information on how to properly fill out a fingerprint card may be found on the
Agency’s website: http://ahca.myflorida.com/MCHQ/Long_Term_Care/Background_Screening/index.shtml .
A Le vel 2 screening was submitted electronically on the Agency’s Background Screening website:
http://ahca.myflorida.com/MCHQ/Long_Term_Care/Background_Screening/logon.shtml ; OR a fingerprint card was sent
directly to the Agency’s Background Screening Unit at BGS Unit, 2727 Mahan Drive, MS 40, Ta llahassee, FL 32308 for the
Administrator and/or Chief Financial Officer. If mailing a fingerprint card directly to the BGS Unit, please attach the
“Background Screening Level 2 Verification” form found at
http://ahca.myflorida.com/MCHQ/Long_Term_Care/Background_Screening/index.shtml .
A Le vel 2 screening fingerprint card was submitted within the previous two years to the Agen cy’s Division of Medicaid as part
of the Medicaid provider application for the Administrator and/or Chief Financial Officer.
Proof of Level 2 screening within the previous 5 years for the Administrator and/or Chief Financial Officer from the
Department of Children and Family, 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, November 2006
(3 pages) is also enclosed.
AHCA Recommended For m Chapter 58A-2, Florida Administrative Code
INSTRUCTION CHECKLIST
B. Additional Information needed for INITIAL Applications:
Certificate of Need
Proof of federal employer identification number from the Internal Revenue Service
Evidence that the applicant has sufficient funds to operate the facility such as bank statements, net worth statements or financial
reports. Please complete and submit the Proof of Financial Ability to Operate, AHCA Recommended Form [available upon request
from the Home Care Unit, (850) 414-6010].
Certificate of occupancy signed by local authorized zoning, building and electrical officials for the principal office
Proof of the applicant’s legal right to occupy the property for the principal office and each satellite office such as a copy of a lease,
rental agreement, contract or deed
Plan for the delivery of services, per section 400.606(1), F.S., including but not limited to:
Monthly patient estimate
List of direct and contracted services (in addition to those listed in section 8 of this application)
Implementation of home care (must be within 3 months of licensure)
Implementation of inpatient care (must be within 12 months of licensure)
Number and disciplines of professional staff to be employed (in addition to those listed in section 8 of this application)
Name and qualifications of any existing or potential contractee(s)
Plan for attracting and training volunteers
Projected annual operating cost
If e xisting licensed health care provider, attach most recent profit-loss statement per section 400.606(1), F.S.
If e xisting licensed health care provider, attach most recent licensure inspection report per section 400.606(1), F.S.
C. Additional Information needed for CHANGE OF OWNERSHIP Applications:
Proof of federal employer identification number from the Internal Revenue Service
Evidence that the applicant has sufficient funds to operate the facility such as bank statements, net worth statements or financial
reports. Please complete and submit the Proof of Financial Ability to Operate, AHCA Recommended Form [available upon request
from the Home Care Unit, (850) 414-6010].
Certificate of occupancy signed by local authorized zoning, building and electrical officials for the principal office if rel ocation will be
part of the change of ownership.
Proof of the applicant’s legal right to occupy the property for the principal office and each satellite office such as a copy of a lease,
rental agreement, contract or deed
Plan for the delivery of services, per section 400.606(1), F.S., including but not limited to:
Monthly patient estimate
List of direct and contracted services (in addition to those listed in section 8 of this application)
Implementation of home care (if not completed by seller within 3 months of initial licensure)
Implementation of inpatient care (if not completed by seller within 12 months of initial licensure)
Number and disciplines of professional staff to be employed (in addition to those listed in section 8 of this application)
Name and qualifications of any existing or potential contractee(s)
Plan for attracting and training volunteers
Projected annual operating cost
If e xisting licensed health care provider, attach most recent profit-loss statement per section 400.606(1), F.S.
If e xisting licensed health care provider, attach most recent licensure inspection report per section 400.606(1), F.S.
Documented evidence of change of ownership such as an asset purchase agreement, bill of sale, stock transfer/sale agreement
and/or proof of corporate reorganization
Signed agreement to correct any existing licensure deficiencies
Statement that administrative records will be retained and available for inspection by the Agency
AHCA Recommended For m Chapter 58A-2, Florida Administrative Code
INSTRUCTION CHECKLIST
D. Change During Licensure Period:
Request to change the name or address of provider:
Complete and submit sections 1, 2 and 14 of the Health Care Licensing Application, Hospice, AHCA Recommended Form,
February 2009.
Complete section 9 for additions/deletions/relocations of satellite offices . (Freestanding inpatient facilities and residential units
may not be relocated without notification to the Agency and a survey.)
For an address change of the principal office, include certificate of occupancy signed by local authorized zoning, bu ilding and
electrical officials for the new location.
For all address changes include proof of applicant’s legal right to occupy the property such as a copy of a lease, rental agreement,
contract or deed.
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 e verything together.
Please do not staple or bind documents submitted to the Agency.
AHCA Recommended For m Chapter 58A-2, Florida Administrative Code
INSTRUCTION CHECKLIST
AHCA USE ONLY:
File #:
Application #:
Check #:
Check Amt:
Batch #:
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Under the authority of Chapters 408, Part II and 400, Part IV, Florida Statutes (F.S.), and Chapter 58A -2, Florida
Administrative Code (F.A.C.), an application is hereby made to operate a hospice as indicated below:
1. Provider / Licensee Information
Provider Inform ation – please complete the following for the hospice nam e and location.
License # (for renewal & change of ownership National Provider Identifier (NPI) CMS CCN (Medicare #) Medicaid #
applications ) (if applicable)
Name of Hospice (if operated under a fic titious name, list that here)
Street Address
City County State Zip
Telephone Number Fax Number E-mail Address
Mailing Address or Same as above
City State Zip
Contact Person for this application Contact Telephone Number
Contact e-mail address or Do not have e-mail
NOTE: By pro viding your e-mail address you agree to accept e-mail
correspondence from the Agency
Licensee Inform ation – please complete the following for the entity seek ing to operate the hospice.
Licensee Name (may be same as provider name above) Federal Employer Identification Number (EIN)
Mailing Address or Same as above
City State Zip
Telephone Number Fax Number E-mail Address
Description of Licensee (check one):
For Profit Not for Profit Public
Corporation Corporation State
Limited Liability Company Church City/County
Partnership Limited Liability Company Hospital District
Individual Other
Other
AHCA Recommended For m, July 2009 Chapter 58A-2, Florida Administrative Code
Page 1 of 8
2. Application Type and Fees
Indicate the type of fees submitted with an “X.” Applications will not be processed if all applicable fees are
not included. Please make check or money order payable to the Agency for Health Care Administration (A HCA).
Pursuant to s. 408.805(4), F.S., fees are nonrefundable.
Initial Licensure
Renewal Licensure
Change of Ownership Proposed Effective Date:
Name/address change (no fee applies) Proposed Effective Date:
Add/delete counties (no fee applies) Proposed Effective Date:
LICENS URE FEE: $1,200.00
Level 2 Background Screening for Administrator $ 43.25
Level 2 Background Screening for Chief Financial Officer $ 43.25
TOTAL FEES INCLUDED WITH APPLICATION: $
Please make check or money order payable to the Agency for Health Care Administration (AHCA)
NOTE: 58A-2.003, F.A.C., requires a hospice to notify the Agency for Health Care Administration (Agency) in writing at least sixty (60)
days before making a change in name or address of the provider’s principal or satellite offices. Freestanding inpatient facilities and
residential units may not be relocated without notification to the Agency and a survey. Please refer to the Agency’s website for further
information on submitting personnel changes and opening satellite offices, inpatient facilities and residential units.
3. Controlling Interests of Licensee
AUTHORITY:
Pursuant to subsections 408.806(1)(a) and (b), Florida Statutes, an application for licensure must include: the name,
address and social security number 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 cont rolling interest is not an individual. Disclosure of social security number(s) is
mandatory. The Agency for Health Care A dministration 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 pers onal information,
do not include social security numbers on thi s form. All social security numbers must be entered on the Health
Care Licensing Application Addendum, AHCA Recommended (3 pages), which must accompany all applications.
DEFINITIONS:
Controlling interests, as defined in subsection 408.803(7), Florida Statutes, 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-percent or greater owners hip interest in the
applicant or licensee; or a person or entity that serves as an offic er of, is on the board of directors of, or has a 5 -percent 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.
Voluntary Board Member, as defined in section 408.803(13), F.S., means a board member or officer of a not-for-profit
corporation or organization who serves solely in a volunt ary capacity, does not receive any remuneration for his or her
services on the board of directors, and has no financial int erest in the corporation or organization.
AHCA Recommended For m, July 2009 Chapter 58A-2, Florida Administrative Code
Page 2 of 8
A. Individual and/or Entity Ownership of Licensee
Provide the following information for each individual or entity (corporation, partnership, association) with 5% or great er
ownership interest in the licensee. Attach additional sheets if necessary.
%
FULL NAME of INDIVIDUAL or BUSINESS ADDRESS EIN
TELEPHONE NUMBER OWNERSHIP
ENTITY (personal address for individuals) (No SSNs)
INTEREST
B. Board Members and Officers of Licensee
Provide the following information for each individual that serves a s an officer or board member (excludes volunt ary
board members) for the licensee listed in Section 1 of this application. Attach additional sheets if necessary.
%
TITLE FULL NAME PERSONAL HOME OR BUSINESS ADDRESS TELEPHONE OWNERSHIP
NUMBER INTEREST
Director/CEO
President
Vice
President
Secretary
Treasurer
Other:
C. Voluntary Board Members and Officers of Licensee
If the licensee is a not-for-profit corporation/organization, provide the following information for each individual that
serve s a s a voluntary board member. Attach additional sheets if necessary.
TELEP HONE
FULL NAME PERS ONAL HOME OR BUSINESS ADDRESS
NUMBER
AHCA Recommended For m, July 2009 Chapter 58A-2, Florida Administrative Code
Page 3 of 8
4. Management Company Controlling Interests
Doe s a company other than the licensee manage the licensed provider?
If NO, skip to section 5 – Required Disclosure.
If YES, provide the following information:
Name of Management Company EIN Telephone Number / Fax
Street Address E-mail Address
City County State Zip
Mailing Address or Same as above
City State Zip
Contact Person Contact E-mail Contact Telephone Number
A. Individual and/or Entity Ownership of Management Company
Provide the following information for each individual or entity (corporation, partnership, association) with 5% or greater ownership
interest in the management company. Attach additional sheets if necessary.
%
EIN
FULL NAME of INDIVIDUAL or PERSONAL OR BUSINESS ADDRESS TELEPHONE NUMBER OWNERSHIP
(No SSNs)
ENTITY INTEREST
B. Board Members and Officers of Management Company
Provide the following information for each individual that serves as an officer or is on the board of directors (excludes voluntary
board members) for the management company. Attach additional sheets if necessary.
%
TITLE FULL NAME PERSONAL OR BUSINESS ADDRESS TELEPHONE OWNERSHIP
NUMBER INTEREST
Director/CEO
President
Vice
President
Secretary
Treasurer
Other:
AHCA Recommended For m, July 2009 Chapter 58A-2, Florida Administrative Code
Page 4 of 8
C. Voluntary Board Members and Officers of Management Company
If the management company is a not-for-profit corporation/organization, provide the following information for each individual tha t
serves as a voluntary board member. Attach additional sheets if necessary.
FULL NAME PERSONAL OR BUSINESS ADDRESS TELEPHONE NUMBER
5. Required Disclosure
For individuals listed in Sections 3 and 4 of thi s application, the following disclosure s are required:
Pursuant to subsection 408.809(1)(d), F.S., the licensee shall submit to the agency a description and explanation of any convicti o ns of
offenses prohibited by section 435.04, F.S. for each controlling interest.
Has any individual listed in sections 3 and 4 of this application been convicted of any level 2 offense pursuant to subsection
408.809(1)(d), Florida Statutes? (These offenses are listed on the Affidavit of Compliance with Background Screening Requirements ,
AHCA Form #3100-0008.) YES NO
If yes, enclose the following information:
The full legal name of the individual and the position held
A description/explanation of the conviction(s) - If the individual has received an exemption from disqualification for the
offense, include a copy.
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 Improvem ent Amendment (CLIA) programs.
Has any individual listed in Sections 3 and 4 of this application been excluded, suspended, terminated or involuntarily withd rawn 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 invol untary withdrawal.
6. Provider Fines and Financial Information
Pursuant to subsection 408.831(1)(a), Florida Statutes, the Agency may take action against the applicant, licensee, or a lice nsee 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 NO
If yes, please complete the following for each incidence (attach additional sheets if necessary):
Amount: $ assessed by: Agency for Health Care Administration Case #: CMS
Date of related inspection, application or overpayment period if applicable:
Due date of payment:
Is there an appeal pending from a Final Order? YES NO
Please attach a copy of the approved repayment plan if applicable.
AHCA Recommended For m, July 2009 Chapter 58A-2, Florida Administrative Code
Page 5 of 8
7. Governing Body
Section 400.610(1), F.S., states, “A hospice shall have a clearly defined organized governing body, consisting of a minimum of seven
persons who are representative of the general population of the community served. The governing body shall have autonomous
authority and responsibility for the operation of the hospice and shall meet at least quarterly.” 58A-2.005(1)(a), F.A.C. further requires,
“Members must reside or work in the hospice’s service area as defined in paragraph 59C -1.0355(2)(k), F.A.C.”
Do the persons listed in section 3 above fulfill the requirements of the hospice’s governing body? Check all that apply:
Section 3A? YES NO Section 3B? YES NO Section 3C? YES NO
If yes, skip to section 8. If no, pro vide the following information for each member of the hospice’s governing body. Attach additional
sheets if necessary. If a listed individual is a paid employee, the individual’s social security number must be included with the Health
Care Licensing Application Addendum , AHCA Recommended Form (3 pages).
TELEPHONE
FULL NAME PERSONAL HOME OR BUSINESS ADDRESS
NUMBER
8. Personnel
Provide the requested information for the individuals who fulfill the required management functions below:
MANAGEMENT FLORIDA LICENSE NUMBER
FULL NAME
FUNCTION (if applicable)
Administrator
Financial Officer N/A
1
Medical Director
Nursing Supervisor2
1
If the medical director has changed since the last application was submitted, please enclose verif ication that this physician has admission priv ileges at
one or more hospitals commonly serving patients in the hospice’s servic e area per 58A-2.014(1), F.A.C.
2
If the nursing supervisor has changed since the last application was submitted, please enclose a resume that documents supervis ory or hospic e
experience as required in 58A-2.0141(1), F.A.C.
Indicate the number of employees under each of the listed services, which are required to be directly provided by the
hospice [58A -2.002(6), F.A.C. recognizes employment on either a salary or volunteer basis.]:
REQUIRED DIRECT SERV ICE NUMBER OF EMPLOYEES
Nursing
Medical Social Work
Pro vided by licensed nutritionist/dietitian/nutrition counselors, registered dietitians
Dietary Counseling
and/or nurses
Pastoral or Counseling
Bereavement Counseling
Volunteer Coordination
AHCA Recommended For m, July 2009 Chapter 58A-2, Florida Administrative Code
Page 6 of 8
9. Satellite Offices
58A-2.002, F.A.C. defines a satellite office as “an office or other physical location serving as a contact point for patients, which is
remote from the provider’s principal office, but is not separately licensed, and shares administration with the principal off ice.”
Does the hospice operate any satellite offices? YES NO If yes, provide the requested information for each below:
NEW
STREET ADDRESS CITY ZIP CODE PHONE # SITE?
Y OR N
10. Freestanding Inpatient Facilities
Does the hospice operate any freestanding inpatient facilities? YES NO
If yes, provide the requested information for each below (Do not list contracted hospital, Skilled Nursing Facility, Nursing Facility or
Intermediate Care Facility beds.):
STREET ADDRESS CITY ZIP CODE PHONE # # BEDS
11. Residential Units
Does the hospice operate any residential units? YES NO
If yes, provide the requested information for each below:
STREET ADDRESS CITY ZIP CODE PHONE # # BEDS
AHCA Recommended For m, July 2009 Chapter 58A-2, Florida Administrative Code
Page 7 of 8
12. Geographic Service Area
Check each county in which this hospic e provides (or will provide) services:
Alachua DeSoto Hendry Levy Osceola Suwannee
Baker Dixie Hernando Liberty Palm Beach Ta ylor
Bay Duval Highlands Madison Pasco Union
Bradford Escambia Hillsborough Manatee Pinellas Volusia
Brevard Flagler Holmes Marion Polk Wakulla
Broward Franklin Indian River Martin Putnam Walton
Calhoun Gadsden Jackson Miami-Dade Santa Rosa Washington
Charlotte Gilchrist Jefferson Monroe Sarasota
Citrus Glades Lafayette Nassau Seminole
Clay Gulf Lake Okaloosa St. Johns
Collier Hamilton Lee Okeechobee St. Lucie
Columbia Hardee Leon Orange Sumter
13. Accreditation with Deemed Status
Has this hospice received accreditation with deemed status through an accrediting organization? YES NO
If yes, indicate the accrediting organization and attach documentation declaring current deemed status from:
The Joint Commission
Community Health Accreditation Program (CHAP)
14. Affidavit
I, , hereby swear or affirm that the statements in this application are true and correct.
Signature of Licensee or Authorized Representative Title
STATE OF
COUNTY OF
Sworn to and subscribed before me this day of , by _______ .
This individual is personally known to me or produced the following identification: ________
Notary Public
NOTAR Y SEAL:
RETURN THIS COMPLETED FORM WITH FEES TO:
AGENC Y FOR HEALTH C ARE AD MINISTR ATION
HOME C ARE UNIT
2727 MAH AN DR MS 34
TALL AHASSEE FL 32308-5407
Questions? Review the information at http://ahca.myflorida.com/
or contact the Home Care Unit at (850) 414-6010.
AHCA Recommended For m, July 2009 Chapter 58A-2, Florida Administrative Code
Page 8 of 8
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