The AHCA Form 3020 is a key form used in the healthcare industry. This form is used to document healthcare services provided to patients, and it helps to ensure that all services provided are accounted for. The AHCA Form 3020 is important for both providers and patients, as it can help to ensure that everyone involved in the patient's care is aware of the services that have been provided. Providers use the AHCA Form 3020 to bill patients or insurance companies for services rendered, while patients can use this form to keep track of their medical history. Overall, the AHCA Form 3020 is an important tool for both providers and patients alike.
| Question | Answer |
|---|---|
| Form Name | Ahca Form 3020 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | discernable deficiencies prefix, ahca licensure forms, ahca form 5000 3502 edit, ahca immediate report form |
Agency for Health Care Administration
Printed: mm/dd/yyyy Form Approved
Statement of Deficiencies |
Health Care Clinic File |
Initial Licensure |
________ |
|
Date Survey Completed |
|
|
and Plan of Correction |
Number |
Renewal |
________ |
|
|
|
|
|
|
|
CHOW |
________ |
|
|
|
|
|
|
Provisional |
________ |
|
|
|
|
|
|
|
|
|
|
|
Name of Clinic |
|
|
Street Address, City, State, ZIP Code |
|
|||
|
|
|
|
|
|
||
PREFIX |
SUMMARY STATEMENT OF DEFICIENCIES |
PREFIX |
|
PLAN OF CORRECTION |
COMPLETE |
||
(EACH DEFICIIENCY MUST BE PRECEED BY FULL |
|
(EACH CORRECTIVE ACTION SHOULD BE CROSS- |
|||||
TAG |
TAG |
|
DATE |
||||
REGUALTORY IDENTIFYIN INFORMATION) |
|
REFERENCED TO THE APPROPRIATE DEFICIENCY) |
|||||
|
|
|
|
||||
INITIAL COMMENTS |
|
|
|
|
|
||
|
There were no discernable deficiencies noted at the |
|
|
|
|
||
|
time of the initial licensure survey on mm/dd/yyyy. |
|
|
|
|
||
|
|
|
|
|
|
|
|
AHCA Form 3020 |
|
|
Medical or Clinic Director’s or Owner’s Representative Signature |
Title |
Date |
If continuation sheet 1 of 1
State Form