DFS Form 3160-0020 "Health Care Provider Application for Certification" - Florida

What Is DFS Form 3160-0020?

This is a legal form that was released by the Florida Department of Financial Services - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Florida Department of Financial Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of DFS Form 3160-0020 by clicking the link below or browse more documents and templates provided by the Florida Department of Financial Services.

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Download DFS Form 3160-0020 "Health Care Provider Application for Certification" - Florida

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Florida Department of Financial Services
Division of Workers’ Compensation, Office of Medical Services
200 East Gaines Street
Tallahassee, FL 32399-4232
HEALTH CARE PROVIDER APPLICATION FOR CERTIFICATION
Name:
Florida DOH License Number:
Profession:
License Expiration Date:
Facility Type:
Facility Name:
Federal Employer Identification Number:
Facility Contact Person:
Address:
Telephone Number:
Fax Number:
HEALTH CARE PROVIDER OR FACILITY AGREES TO THE FOLLOWING:
1.
To have access to and be familiar with the applicable Division of Workers’ Compensation Manuals/Rules.
2.
To follow the policies and procedures therein.
3.
To have knowledge of all statements authorized under my signature and to be responsible for the content of all bills
submitted pursuant to the fraud provision in s. 440.105, Florida Statutes.
4.
Completion of the specific Workers’ Compensation certification training course pursuant to 69L-29, Florida
Administrative Code, on
(MM/DD/YY), in
(city),
Florida, by
(course sponsor name).
CERTIFICATION TRAINING COURSE:
Initial
Repeat
Exempt*
1.
Has your professional license or the license of the facility been revoked, suspended,
Yes
No
or voluntarily relinquished within the past twelve months?
2.
Have you been, placed on probationary status by a professional credentialling body
Yes
No
within the past twelve months?
3.
Have you or your facility been convicted within the past twelve months or are you
Yes
No
currently under charges of any felony, crime, or ethical violation?
4.
Are you currently decertified pursuant to 69L-29.006, Florida Administrative Code?
Yes
No
IF YOU ANSWER YES TO ANY OF THE ABOVE QUESTIONS, ATTACH AN EXPLANATION AND FINAL DECREE.
*Exempt pursuant to 69L-29.004, Florida Administrative Code.
DFS Form 3160-0020
Page 1 of 2
Florida Department of Financial Services
Division of Workers’ Compensation, Office of Medical Services
200 East Gaines Street
Tallahassee, FL 32399-4232
HEALTH CARE PROVIDER APPLICATION FOR CERTIFICATION
Name:
Florida DOH License Number:
Profession:
License Expiration Date:
Facility Type:
Facility Name:
Federal Employer Identification Number:
Facility Contact Person:
Address:
Telephone Number:
Fax Number:
HEALTH CARE PROVIDER OR FACILITY AGREES TO THE FOLLOWING:
1.
To have access to and be familiar with the applicable Division of Workers’ Compensation Manuals/Rules.
2.
To follow the policies and procedures therein.
3.
To have knowledge of all statements authorized under my signature and to be responsible for the content of all bills
submitted pursuant to the fraud provision in s. 440.105, Florida Statutes.
4.
Completion of the specific Workers’ Compensation certification training course pursuant to 69L-29, Florida
Administrative Code, on
(MM/DD/YY), in
(city),
Florida, by
(course sponsor name).
CERTIFICATION TRAINING COURSE:
Initial
Repeat
Exempt*
1.
Has your professional license or the license of the facility been revoked, suspended,
Yes
No
or voluntarily relinquished within the past twelve months?
2.
Have you been, placed on probationary status by a professional credentialling body
Yes
No
within the past twelve months?
3.
Have you or your facility been convicted within the past twelve months or are you
Yes
No
currently under charges of any felony, crime, or ethical violation?
4.
Are you currently decertified pursuant to 69L-29.006, Florida Administrative Code?
Yes
No
IF YOU ANSWER YES TO ANY OF THE ABOVE QUESTIONS, ATTACH AN EXPLANATION AND FINAL DECREE.
*Exempt pursuant to 69L-29.004, Florida Administrative Code.
DFS Form 3160-0020
Page 1 of 2
The following photocopy attachments are required with this application if you are NOT LICENSED by the Department of
Health, either:
-
CURRENT FLORIDA MEDICAL SCHOOL TEACHING CERTIFICATE;
-
CURRENT TEMPORARY CERTIFICATE IN AN AREA OF CRITICAL NEED PURSUANT TO S. 458.315, FLORIDA
STATUES, FOR MEDICALLY CRITICAL AREAS.
Signature:
Date:
IMPORTANT! The Department will return a copy of this page within 90 days of receipt as proof of your certification. In
order to ensure and expedite this process, please print or type your mailing address in the box below.
MAILING ADDRESS:
DEPARTMENT CERTIFICATION STAMP
FOR OFFICIAL USE ONLY:
CERTIFICATION:
CONFERRED
DENIED
REASON FOR DENIAL:
Additional requirements needed:
Yes
No
DFS Form 3160-0020
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