Get Fl Ahca 3110-0019 2017-2026

The FL AHCA 3110-0019 form is an essential application for individuals seeking an exemption from disqualification to work in health care settings. This guide aims to provide clear and comprehensive instructions on how to complete the form online, ensuring you provide all necessary information to support your application.

Follow the steps to complete the FL AHCA 3110-0019 form online.

1. Click the ‘Get Form’ button to access the FL AHCA 3110-0019 application online and start filling it out.
2. Begin with section 1, Personal Information. Fill in your last name, first name, middle name, and mailing address. Provide your maiden name, phone number with area code, city, state, zip code, social security number, date of birth, sex, race, and email address (optional). If you have applied for an exemption with another state agency, indicate this as well.
3. In section 2, Employment Information, specify the name and address of your current or prospective employer, along with their phone number. Indicate the type of health care provider and the position for which you are seeking an exemption.
4. Move to section 3, Employment History. List each employer for the past five years, including names, addresses, supervisors, job titles, employment dates, responsibilities, and reasons for leaving. Attach additional sheets if necessary.
5. Complete section 4, Education/Training. Indicate your highest level of education completed and provide details on any health-related certification or licensure training program you have engaged in, including the name of the school/program and the status of training completion.
6. In section 5, Confirmation to request an exemption review, confirm your understanding of the application and sign your name. Ensure the information is accurate and complete.
7. Once all sections are filled out, review the entire application for accuracy. Save your changes, download the form for your records, or print it if necessary. Ensure you have all required documentation ready to submit along with your application.

Complete your FL AHCA 3110-0019 application online today to ensure a smooth submission process!