Fillable ACN Facility Request4 (Florida Department of Health)

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ACN Facility Request4 (Florida Department of Health)

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File type: PDF

U.S.A. forms for Florida Department of Health

BROWSE FLORIDA DEPARTMENT OF HEALTH (FL) FORMS

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Florida Department of Health Page 1
Revised April 2016
_________________________________________________________________________________________________________
Area of Critical Need Facility Designation Request Application
(Please complete an individual form for each clinic site location requested)
PLEASE TYPE OR PRINT CLEARLY
I. Contact Information:
Name: Last:
First:
Middle:
Email Address:
Telephone Number:
II. Clinic Site Information:
Name of Practice:
Business Name:
Owner Name and Title:
Please Check One: Ms. Mrs. Mr. Dr.
Email Address:
Telephone Number:
Physical Street Address:
State:
Zip:
County:
Type: of Medical Practice:
Please submit application electronically to: volunteers@flhealth.gov
FOR DEPARTMENT USE ONLY:
Date Request Received:
In a HPSA: Yes No
Application Status: In Process In Review Approved Denied
Business License Submitted: Yes No
Date of Approval or Denial:
Comments:
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ACN Facility Request4 (Florida Department of Health)

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Completed 18 July 2020

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