Florida 3170 Form in PDF
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The Florida 3170 form is a crucial document for clinical laboratories seeking to add specialties or make changes to their licensing outside of the standard renewal period. This application checklist outlines the necessary steps and required attachments as mandated by Florida law. To avoid late fees, applicants must submit their forms at least 60 days before their current license expires or a change in ownership takes effect. If submitted late, a fee will be assessed, and the application may be withdrawn if all required documents are not provided within 21 days of receiving an omission notice. Key components of the application include evidence of the director's qualifications, completion of a federal CMS 116 form, and a Level 2 background screening for both the Lab Director and Financial Officer, which must be updated every five years. The application also specifies the need for proper fees, which are nonrefundable, and outlines the process for fingerprinting if the individuals are located out of state. By ensuring all documentation is complete and accurate, applicants can navigate the licensing process effectively, thereby maintaining compliance with the Florida Agency for Health Care Administration's regulations.
Form Example
Document Breakdown
| Fact Name | Description |
|---|---|
| Governing Laws | The Florida 3170 form is governed by Chapter 483, Part I, Florida Statutes (F.S.), Chapter 408, Part II, F.S., and Chapters 59A-35 and 59A-7 of the Florida Administrative Code (F.A.C.). |
| Application Purpose | This form is specifically for the licensing of clinical laboratories, particularly for the addition of specialties or subspecialties that occur outside of the regular license renewal period. |
| Submission Deadline | Applicants must submit the form at least 60 days before the current license expires to avoid late fees. |
| Late Fees | If the application is submitted less than 60 days before expiration, it will incur a late fee, which will be communicated to the applicant. |
| Withdrawal of Application | The application will be withdrawn if all required documents and fees are not submitted within 21 days of receiving an omission notice. |
| Licensure Fee | The licensure fee is outlined in section 483.172, F.S., and is nonrefundable. Payments must be made via check or money order. |
| Background Screening | Level 2 background screening is required for the Lab Director and Financial Officer every five years, and results must be submitted to the Agency for review. |
| Fingerprint Submission | If out-of-state individuals do not have access to a Florida LiveScan vendor, they must submit a fingerprint card along with a processing fee. |
| Document Organization | To facilitate electronic storage, applicants should place checks, money orders, and fingerprint cards on top of the application and paperclip all documents together, avoiding staples. |
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