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Ref-05435 Application for Exemption, AHCA Form 3110-0019, May 2015

Application for Exemption AHCA Form 3110 0019.docx

Application for an exemption from disqualification for background screenings.

Application for Exemption AHCA Form 3110 0019.pdf

Technical changes were made to add an informational statement regarding the collection of social security numbers. 6/28/2016

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Agency:: Agency for Health Care Administration
59A. Health Facility and Agency Licensing

Description:: Application for an exemption from disqualification for background screenings.

Related Rules

59A-35.090 Background Screening; Prohibited Offenses.

Related Notices

19158875.This rule will be revised to strike language regarding submission of the Attestation of Compliance with Background Screening Requirements, AHCA Form 3100-0008, when submitting an application for health care facility licensure and incorporate changes to AHCA Form 3110-0019, Backgound Screening Application for Exemption.