AHCA Form 3180-1006 "Notification of Change of Administrator" - Florida

What Is AHCA Form 3180-1006?

This is a legal form that was released by the Florida Agency For Health Care Administration - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2016;
  • The latest edition provided by the Florida Agency For Health Care Administration;
  • 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 printable version of AHCA Form 3180-1006 by clicking the link below or browse more documents and templates provided by the Florida Agency for Health Care Administration.

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Download AHCA Form 3180-1006 "Notification of Change of Administrator" - Florida

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CONFIDENTIAL DOCUMENT
Assisted Living Facilities
NOTIFICATION OF
CHANGE OF ADMINISTRATOR
AUTHORITY: In accordance with Section 429.11(1), Florida Statutes (F.S.) each assisted living facility must identify the administrator
The law also requires the collection of the administrator’s social security
of the facility and each facility that he/she currently operates.
number.
Facility Information
ALF License #:
Assisted Living Facility Name
Telephone Number
Street Address
Fax
City
County
State
Zip
Email Address
New Administrator Personal Information
Effective Date of Change:
Administrator Name
Social Security Number
Date of Birth
Mailing Address
Email Address
Telephone Number
City
County
State
Zip
NOTE: Pursuant to Section 408.809, Florida Statutes, all facility administrators are subject to Level 2 background screening.
Please review the information available at:
http://ahca.myflorida.com/MCHQ/Central_Services/Background_Screening/
A. Is the administrator a licensed Nursing Home administrator Pursuant to Chapter 468, Part II Florida Statutes?
YES
NO
If Yes, License Number:
B. Does the administrator have a high school diploma or GED certificate?
YES
NO
GED
Please attach a copy of the high school diploma or GED certificate.
AHCA Form 3180-1006, June 2016
Section 429.11(1), F.S., 58A-5.019(1), F.A.C.
Page 1 of 2
Forms available at:
http://ahca.myflorida.com/MCHQ/HQALicensureForms/index.shtml
CONFIDENTIAL DOCUMENT
Assisted Living Facilities
NOTIFICATION OF
CHANGE OF ADMINISTRATOR
AUTHORITY: In accordance with Section 429.11(1), Florida Statutes (F.S.) each assisted living facility must identify the administrator
The law also requires the collection of the administrator’s social security
of the facility and each facility that he/she currently operates.
number.
Facility Information
ALF License #:
Assisted Living Facility Name
Telephone Number
Street Address
Fax
City
County
State
Zip
Email Address
New Administrator Personal Information
Effective Date of Change:
Administrator Name
Social Security Number
Date of Birth
Mailing Address
Email Address
Telephone Number
City
County
State
Zip
NOTE: Pursuant to Section 408.809, Florida Statutes, all facility administrators are subject to Level 2 background screening.
Please review the information available at:
http://ahca.myflorida.com/MCHQ/Central_Services/Background_Screening/
A. Is the administrator a licensed Nursing Home administrator Pursuant to Chapter 468, Part II Florida Statutes?
YES
NO
If Yes, License Number:
B. Does the administrator have a high school diploma or GED certificate?
YES
NO
GED
Please attach a copy of the high school diploma or GED certificate.
AHCA Form 3180-1006, June 2016
Section 429.11(1), F.S., 58A-5.019(1), F.A.C.
Page 1 of 2
Forms available at:
http://ahca.myflorida.com/MCHQ/HQALicensureForms/index.shtml
CONFIDENTIAL DOCUMENT
C. Is the administrator Core Trained?
YES
NO
If Yes, Provide ID Number:
D. Will the administrator be serving as the administrator for more than this ALF?
YES
NO
Note: An administrator may manage a maximum of 3 ALFs.
If yes, please complete the following:
Name of Facility
License Number
PRINT the Name of Licensee or Authorized Representative
Signature of Licensee or Authorized Representative
Title
Date
Send completed forms to: Agency for Health Care Administration, Assisted Living Unit, 2727 Mahan Drive, Mail
Stop 30, Tallahassee, FL 32308 or email completed forms to:
assistedliving@ahca.myflorida.com
Questions?
Review the information available at
http://ahca.myflorida.com/
or contact the Assisted Living Unit at:
Phone: (850) 412-4304
Fax: (850) 922-1984
Email:
assistedliving@ahca.myflorida.com
AHCA Form 3180-1006, June 2016
Section 429.11(1), F.S., 58A-5.019(1), F.A.C.
Page 2 of 2
Forms available at:
http://ahca.myflorida.com/MCHQ/HQALicensureForms/index.shtml
Page of 2