DH5038-MQA-07/2019, Rule 9.008, F.A.C. Page 1 of 1
Change of Registered Agent
and/or Registered Office
Out-of-State Telehealth Provider
Completed forms must be sent to:
Telehealth
4052 Bald Cypress Way, Bin C-11
Tallahassee, FL 32399-1708
Email: MQA.Telehealth@flhealth.gov
TELEHEALTH PROVIDER INFORMATION:
Name:
______________________________________________________________________________________________
Last/Surname First Middle
Address: __________________________________________________________________________ _______
Street/P.O. Box Apt. No.
_______________________ ______________ _________
I acknowledge this document is
being
submitted to
notify the
D
epartment
of Health
of a change of registered
agent and/or
registered
office.
Telehealth
Provider’s
Signature:
___________________________________________
Date:
___________
You may print out the
form
and sign it or sign digitally.
MM/DD/YYYY
City
State
ZIP
Telehealth Registration Number:
____________________________
REGISTERED AGENT INFORMATION:
The agent must be registered
with
the
Florida Department of State, Division of
Corporations, and the agent’s name
must appear on the Registered Agent Name List maintained by the Division of Corporations.
The name and street address of the registered agent
you have designated to receive
service of process
is required by
section 456.47(4)(b), F.S,
and this information must be updated if there is a change in the registered agent and/or the
registered office.
Name
of Registered Agent:
__________________________________________________________________________
Physical Address:
__________________________________________________________________________ _______
Street (cannot be a P.O. Box)
Apt. No.
Floridax
sssssssss______________
____
__
____
_________
City
State ZIP
click to sign
signature
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click to sign
signature
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