Florida Department of State and Division of Library and Information Services

Reference: Ref-05435

Reference Name: Application for Exemption, AHCA Form 3110-0019, May 2015
Agency: 59 Agency for Health Care Administration
59A Health Facility and Agency Licensing

Modified Document(s):
6/28/2016 Technical changes were made to add an informational statement regarding the collection of social security numbers.
1/17/2018 Uploading a new form. Submitting a new form and in order to adjust the date.
Original Document(s):
5/8/2015 Application for an exemption from disqualification for background screenings.
Description: Application for an exemption from disqualification for background screenings.

Disclaimer: External links within the reference material are subject to change outside of the rulemaking process.

Rules/Notices using this Reference Material
Notice /
Adopted		 Section Description ID Publish
Date
View Text Proposed
59A-35.090 		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 .... 19158875 7/7/2017
Vol. 43/131
View Text Final
59A-35.090 		Background Screening; Prohibited Offenses. 16060889 Effective:
06/15/2015



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