Content Overview
Understanding Florida 3170
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What is the Florida 3170 form?
The Florida 3170 form is an application for licensing clinical laboratories in Florida. It is specifically for non-waived laboratories seeking to add a specialty, subspecialty, or change in specialty outside of the regular licensure renewal process.
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What attachments are required with the Florida 3170 form?
Applicants must include several attachments as mandated by Florida Statutes and Administrative Code. Required documents include:
- A completed federal CMS 116 form.
- A copy of the medical or professional license.
- Evidence that the lab director is qualified, showing laboratory experience or training.
- Proof of Level 2 background screening for the Lab Director and Financial Officer.
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What happens if the application is submitted late?
To avoid a late fee, applications must be received at least 60 days before the expiration of the current license. If submitted late, the application will incur a late fee, which the applicant will be notified about during the application process. If all required documents are not submitted within 21 days of receiving an omission notice, the application will be withdrawn.
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How should I submit the completed Florida 3170 form?
Submit the completed application to the following address:
Agency for Health Care Administration, Lab Unit,
2727 Mahan Drive, Mail Stop 32,
Tallahassee, FL 32308. -
What are the fees associated with the Florida 3170 form?
The licensure fee is outlined in Section 2 of the application and is nonrefundable. Payment should be made via check or money order, payable to the Agency for Health Care Administration. Note that starter checks and temporary checks are not accepted.
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What is the background screening requirement?
A Level 2 background screening is required for both the Lab Director and Financial Officer every five years. This screening must be submitted to the Agency for review. If using a LiveScan vendor, ensure they are approved by the Florida Department of Law Enforcement. If the director or officer is out of state, a fingerprint card must be obtained from the Agency and submitted to a designated vendor.
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Can I access the necessary forms online?
Yes, all required forms, including the Florida 3170 form and the Background Screening Validation form, can be accessed through the Agency for Health Care Administration's website. Ensure you download the most current version of each form for your application.
Common mistakes
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Submitting Late: Applications must be received at least 60 days prior to the expiration of the current license. Failing to meet this deadline may result in a late fee.
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Omitting Required Documents: All necessary documents and fees must accompany the application. If any are missing, the application may be withdrawn after 21 days of an omission notice.
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Incorrect Payment Method: Payments must be made via check or money order. Starter checks and temporary checks are not accepted.
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Improperly Completed Fingerprint Card: The fingerprint card must be filled out completely and taken by trained personnel. Incomplete cards will delay the application process.
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Neglecting Background Screening: Level 2 background screenings are required for both the Lab Director and Financial Officer. Failing to provide this can lead to application rejection.
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Using Non-Approved LiveScan Vendors: If opting for a LiveScan vendor other than the Agency’s, ensure the correct ORI is provided and results are sent to the Agency.
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Not Providing Proof of Qualifications: Evidence that the Lab Director is qualified must be included. Documentation of laboratory experience or training is essential.
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Missing Affidavit of Compliance: An Affidavit of Compliance with Background Screening Requirements must be enclosed. Omitting this can lead to delays.
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Incorrectly Assembling the Application: Place checks, money orders, and fingerprint cards on top of the application and paperclip everything together. Do not staple or bind documents.
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Ignoring Application Checklist: Failure to follow the application checklist can result in missing critical components, causing delays or rejection of the application.
How to Use Florida 3170
Filling out the Florida 3170 form is an important step in the process of applying for a clinical laboratory license. This form requires specific information and documentation, so it’s essential to follow the instructions carefully to ensure a smooth submission. Below are the steps you need to take to complete the form correctly.
- Obtain the Florida 3170 form from the Agency for Health Care Administration’s website or office.
- Review the application checklist provided on the form. Ensure you have all necessary attachments, including:
- A completed federal CMS 116 form.
- A copy of the medical or professional license.
- Evidence that the lab director is qualified, including documentation of laboratory experience or training.
- Proof of Level 2 background screening for the Lab Director and Financial Officer.
- Fill out the application form completely. Provide accurate information regarding the lab’s details, ownership, and specialty changes.
- Include the licensure fee as stated in Section 2 of the application. Make your payment via check or money order made out to the Agency for Health Care Administration. Remember, starter checks and temporary checks are not accepted.
- If applicable, ensure that the Lab Director and Financial Officer have submitted Level 2 screenings through an approved LiveScan vendor. If they are out of state, request a fingerprint card from the Agency and follow the instructions for submission.
- Gather all required documents and place them in the order specified in the checklist. This includes the application form, payment, and any additional documentation.
- Paperclip all documents together, ensuring that checks, money orders, and fingerprint cards are on top. Do not staple or bind the documents.
- Send the completed application package to the following address: Agency for Health Care Administration, Lab Unit, 2727 Mahan Drive, Mail Stop 32, Tallahassee, FL 32308.
- Keep a copy of the submitted application and all attachments for your records.
After you have submitted the application, the Agency will review it and notify you if any additional information is needed. Be aware that if the application is not complete, it may be withdrawn from review. Therefore, double-check that all required documents and fees are included before sending your application.
File Specs
| Fact Name | Details |
|---|---|
| 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 used for the Health Care Licensing Application for Clinical Laboratories (Non-Waived) to add or change specialties or subspecialties outside of the licensure renewal period. |
| Submission Deadline | Applications must be submitted at least 60 days before the expiration of the current license to avoid late fees. |
| Late Fee Notification | If submitted late, applicants will receive a notice detailing the late fee as part of the application process. |
| Document Requirements | All required documents and fees must be included with the application or received within 21 days of an omission notice; otherwise, the application will be withdrawn. |
| 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 | A Level 2 background screening for the Lab Director and Financial Officer is required every five years. |
| Fingerprint Submission | If using a fingerprint card, it must be obtained from the Agency and submitted to Cogent Systems with a fee of $58.25. |
| Electronic Document Handling | Documents should be organized with checks and fingerprint cards on top, and applicants are advised not to staple or bind their submissions. |
Additional PDF Forms
Florida Financial Affidavit Short Form - Parties may seek legal assistance to ensure accuracy and completeness of the affidavit.
Abortion Papers Pdf - This form requires the recipient's name and address to establish identity and location.