13. Supporting Documents Applicants must include the following attachments as stated in Chapters 408, Part II and Chapter 400, Part III, F.S. and Chapters and 59A-8, F.A.C. Note: Required documents listed below are dependent on the type of application being submitted. (Initial, Renewal, Change of Ownership, Change during Licensure Period) Documents to be Provided: Required for: Initial, Renewal, Change of Ownership and Address Change Proof of Liability and Malpractice Insurance Coverage application types (excluding change of geographic service area) Evidence of a Surety Bond Initial, Renewal and Change of Ownership application types Initial, Renewal, Change of Ownership and Address Change Proof of Accreditation documentation and report – application types (excluding change of geographic service area) of Financial Ability to Operate, AHCA Form 3100-0009 Initial and Change of Ownership application Business plan, signed by the applicant, detailing the home health agency’s methods to obtain patients and its plan to recruit and Initial and Change of Ownership application types maintain staff. Proof of legal right to occupy the property for principal office and Initial, Change of Ownership involving change of licensee and each satellite office, inpatient facility and residential unit change of address application types Documentation signed by the appropriate local government Initial, Change of Ownership and change of address application official, which states that the applicant has met local zoning types requirements. Address Change application type, for addition of counties within Plan for delivery of services per Rule 59A-8.007(2), F.A.C. geographic service area only of Medicare branch approval, if home health agency is Address Change application type, for addition of satellite offices certified only Documentation of change of ownership transaction stating Change of Ownership application and any change of controlling effective date and executed by all parties interest affecting % ownership of licensee application types Health Care Licensing Application Addendum, AHCA Form Initial, Renewal and Change of Ownership application types 3110-1024 Attestation of Compliance with Background Screening Initial, Renewal and Change of Ownership application types, if Requirements, AHCA Form 3100-0008 for administrator and background screening was conducted by a state agency other financial officer than the Agency for Health Care Administration Exemption from disqualification for documented offense, if All application types applicable. Required disclosures related to actions taken by Medicare, All application types, if documentation is required due to Medicaid or CLIA, if applicable responses provided in application Approved repayment plan, if applicable All application types
13. Supporting Documents Applicants must include the following attachments as stated in Chapters 408, Part II and Chapter 400, Part III, F.S. and Chapters and 59A-8, F.A.C. Note: Required documents listed below are dependent on the type of application being submitted. (Initial, Renewal, Change of Ownership, Change during Licensure Period) Documents to be Provided: Required for: Proof of Liability and Malpractice Insurance Coverage Initial, Renewal, Change of Ownership and Address Change application types (excluding change of geographic service area) Evidence of a Surety Bond Initial, Renewal and Change of Ownership application types Proof of Accreditation – documentation and report Initial, Renewal, Change of Ownership and Address Change application types (excluding change of geographic service area) of Financial Ability to Operate, AHCA Form 3100-0009 Initial and Change of Ownership application Business plan, signed by the applicant, detailing the home health agency’s methods to obtain patients and its plan to recruit and maintain staff. Initial and Change of Ownership application types Proof of legal right to occupy the property for principal office and each satellite office, inpatient facility and residential unit Initial, Change of Ownership involving change of licensee and change of address application types Documentation signed by the appropriate local government official, which states that the applicant has met local zoning requirements. Initial, Change of Ownership and change of address application types Plan for delivery of services per Rule 59A-8.007(2), F.A.C. Address Change application type, for addition of counties within geographic service area only of Medicare branch approval, if home health agency is certified Address Change application type, for addition of satellite offices only Documentation of change of ownership transaction stating effective date and executed by all parties Change of Ownership application and any change of controlling interest affecting % ownership of licensee application types Health Care Licensing Application Addendum, AHCA Form 3110-1024 Initial, Renewal and Change of Ownership application types Attestation of Compliance with Background Screening Requirements, AHCA Form 3100-0008 for administrator and financial officer Initial, Renewal and Change of Ownership application types, if background screening was conducted by a state agency other than the Agency for Health Care Administration Exemption from disqualification for documented offense, if applicable. All application types Required disclosures related to actions taken by Medicare, Medicaid or CLIA, if applicable All application types, if documentation is required due to responses provided in application Approved repayment plan, if applicable All application types