AHCA Form 3020 is issued by the Florida Agency for Health Care Administration to document regulatory deficiencies found during health care clinic licensure surveys. It is the official record of violations of Florida health care standards and the clinic's required plan of correction.
Each deficiency entry references the specific state regulation violated. The clinic must describe the corrective steps it will take and provide a target completion date for each action.
The completed form must be signed by the medical director, clinic director, or authorized owner's representative before submission to AHCA. Related forms in the AHCA licensure process include AHCA Form 1823 and AHCA Form 3100-0008.
| Question | Answer |
|---|---|
| Form Name | AHCA Form 3020 |
| Form Type | Statement of Deficiencies and Plan of Correction |
| Issued by | Florida Agency for Health Care Administration |
| Form Length | 1 page |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | Statement of Deficiencies, AHCA Survey Form, Florida Health Care Clinic Deficiency Report |