Additional Nursing Home Applications & Forms
Bernard E. Hudson
Manager, Long Term Care Services Unit
Bureau of Health Facility Regulation
2727 Mahan Drive MS#33
Tallahassee, FL 32308
Florida Relay Service (TDD): (800) 955-8771
Phone: (850) 412-4303
Email: LTCStaff@ahca.myflorida.com
- Applications and Forms
- Gold Seal Application
- Transfer and Discharge Forms
- Transfer Discharge Notice [185KB, PDF]
- Spanish Version [32KB, PDF]
- Transfer Discharge Fair Hearing Request [80KB, PDF]
- Spanish Version [7KB, PDF]
- Transfer Discharge LTC Ombudsman Request [718KB, PDF]
- Spanish Version [736KB, PDF]
- Transfer Discharge Notice [185KB, PDF]
Miscellaneous Forms
- Bed Change Request Form [88KB, PDF]
- Bed_Change_Request_Instructions [172KB, PDF]
- Bed_Change_Room_List_Form [205KB, PDF]
- Emergency Management Planning [53KB, PDF]
- Fire Incident Reporting and System Failure
- Fire Incident Reporting Form [90KB, PDF]
- Unconditional Guarantee of Payment form [10KB, PDF]
- State Nursing Staff Calculation Forms
- Hotline Poster (can be printed on 8 1/2" x 14" or 11" x 17") - English [1011KB, PDF]
- Hotline Poster (can be printed on 8 1/2" x 14" or 11" x 17") - Creole [1012KB, PDF]
- Hotline Poster (can be printed on 8 1/2" x 14" or 11" x 17") - Spanish [1012KB, PDF]
- Hotline Poster (can be printed up to 36" x 48" - special paper/printer required) - English [1.51MB, PDF]
- Hotline Poster (can be printed up to 36" x 48" - special paper/printer required) - Creole [1.51MB, PDF]
- Hotline Poster (can be printed up to 36" x 48" - special paper/printer required) - Spanish [1.51MB, PDF]
Consumer Guides
- Nursing Home Guide
- Nursing Home Watchlist
- Guidade Hogares de Ancianos (Spanish Nursing Home Guide)