AGENCY FOR HEALTH CARE ADMINISTRATION
Health Facility and Agency Licensing
RULE NO.:RULE TITLE:
59A-6.020Licensure Procedure
NOTICE OF CHANGE
Notice is hereby given that the following changes have been made to the proposed rule in accordance with subparagraph 120.54(3)(d)1., F.S., published in Vol. 39, No. 245, December 19, 2013 issue of the Florida Administrative Register.
The following sections of the proposed rule will be changed to read:
59A-6.020 Licensure Procedure.
(1) through (2)(k) No change.
(l) Such other information requested on the Health Care Licensing Application, Multiphasic Health Testing Center, AHCA form 3170-4001, July 2014 Revised January 2014, incorporated by reference. This form is available at http://www.flrules.org/Gateway/reference.asp?No=Ref-XXXXX and available from the Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop 32, Tallahassee, Florida 32308, or at the web address at: http://ahca.myflorida.com/HQALicensureForms.
(m) through new (6) No change.
The following changes have been made to the Application Checklist on the Health Care Licensing Application, Multiphasic Health Testing Center, AHCA Form 3170-4001, January 2014:
Pgs. 1-2: The form revision date was updated to change the revision date from “January 2014” to “July 2014”.
Pg. 1: The Agency logo has been updated.
The following changes have been made to the Health Care Licensing Application, Multiphasic Health Testing Center, AHCA Form 3170-4001, January 2014:
Pgs. 1-7: The form revision date was updated to change the revision date from “January 2014” to “July 2014”.
Pg. 1: The Agency logo has been updated.
Pg. 3, Section 3.C. and 3.D.:
Section C., Voluntary Board Members and Officers of Licensee has been removed and Section D., Administration has been renumbered to Section C.
Pg. 5, Section 4.C.:
Section C., Voluntary Board Members and Officers of Management Company has been removed.
Pg. 7 (formerly Pg. 6), Section 10. Affidavit
The section title has been changed from “Affidavit” to “Attestation”.
The statements in this section have been replaced with the following:
I, __________________________, under penalty of perjury, attest as follows:
(1) Pursuant to Section 837.06, Florida Statutes, I have not knowingly made a false statement with the intent to mislead the Agency in the performance of its official duty.
(2) Pursuant to Section 408.815, Florida Statutes, I acknowledge that false representation of a material fact in the license application or omission of any material fact from the license application by a controlling interest may be used by the Agency for denying and revoking a license or change of ownership application.
(3) Pursuant to section 408.806, Florida Statutes, the applicant is in compliance with the provisions of Section 408.806 and Chapter 435, Florida Statutes.
(4) Pursuant to sections 408.809 and 435.05, Florida Statutes, every employee of the applicant required to be screened has attested, subject to penalty of perjury, to meeting the requirements for qualifying for employment pursuant to Chapter 408, Part II, and Chapter 435, Florida Statutes, and has agreed to inform the employer immediately if arrested for any of the disqualifying offenses while employed by the employer.
(5) Pursuant to Section 435.05, Florida Statutes, the applicant has conducted a level 2 background screening through the Agency on every employee required to be screened under Chapter 408, Part II, or Chapter 435, Florida Statutes, as a condition of employment and continued employment and that every such employee has satisfied the level 2 background screening standards or obtained an exemption from disqualification from employment.
