Get Fl Ahca Form 3110-1003 2023-2025

Filling out the FL AHCA Form 3110-1003 online is a crucial step for individuals and organizations applying for a homemaker and companion services provider license in Florida. This guide will walk you through each section and field of the form, ensuring you have the necessary information to complete it accurately and efficiently.

Follow the steps to successfully complete the application process.

1. Press the ‘Get Form’ button to access and open the form in your online editor.
2. Begin with Section 1A, 'Provider Information,' where you must enter the name, address, and contact details of the homemaker and companion service. Include the registration number and National Provider Identifier if applicable.
3. In Section 1B, complete the 'Property Owner Information' if the property is owned by someone other than the licensee. If not applicable, skip to Section 1C.
4. Fill in Section 1C for the 'Contact Person' relating to this application, ensuring you include their email and telephone number.
5. Section 1D requests information about the 'Licensee Information.' Complete this section with details about the entity operating the service, including the business name, its registered type, and contact information.
6. Move to Section 2 for 'Application Type and Fees,' mark the relevant application choice, and ensure the applicable fees are included to avoid processing delays.
7. Complete Section 3 for 'Controlling Interests of Licensee,' entering the required information for individuals or entities with significant ownership interest.
8. In Section 4, provide information regarding any 'Management Company' if applicable. If no management company is involved, proceed to Section 6.
9. Section 6 requires details about the 'Personnel,' specifically the administrator and financial officer roles. Fill out the necessary fields accordingly.
10. Section 7 includes required disclosures concerning any legal issues or disqualifications, needing you to provide relevant details where applicable.
11. In Section 8, disclose any outstanding fines, liens, or payments due to AHCA and include necessary documentation.
12. Section 9 allows you to define your 'Geographic Service Area.' Choose the service area and check the counties that will be served.
13. List the 'Hours of Operation' in Section 10, clearly stating your schedule for inspections.
14. Assemble the 'Supporting Documents' required in Section 11 based on your application type.
15. Finally, complete the 'Attestation' section with a signature from the licensee or authorized representative, date it, and ensure it is correctly filed.
16. Once everything is filled out, save your changes, download, print, or share the completed form as required.

Start filling out your FL AHCA Form 3110-1003 online today!