Cna License To Florida PDF Details

Moving to Florida as a Certified Nursing Assistant (CNA) involves navigating through specific bureaucratic processes, with the CNA License to Florida form playing a pivotal role in this transition. This comprehensive application checklist is designed to ensure that candidates submit a complete and accurate application to expedite their approval process effectively. Applicants must ensure that every question on the form is answered honestly since the Board of Nursing may deny applications containing false information. The necessity of proof of active certification from another state, which must be clear, active, and in good standing, underscores the rigorous standards upheld by Florida's health sector. Additionally, the inclusion of a Livescan is required for all applications, signifying the state's commitment to maintaining high safety standards by necessitating electronically submitted fingerprints from approved providers. The checklist also highlights critical updates and notifications such as changes in personal information, criminal history, and any disciplinary actions or healthcare fraud, which can significantly impact the application's outcome. Hence, the form not only serves as a procedural necessity but also as a tool to ensure that those entering the healthcare workforce in Florida are qualified, ethical, and capable of upholding the high standards expected by the Department of Health.

QuestionAnswer
Form NameCna License To Florida
Form Length15 pages
Fillable?No
Fillable fields0
Avg. time to fill out3 min 45 sec
Other namescna reciprocity in florida, florida cna reciprocity form, cna reciprocity florida, transfer cna license to florida

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Application Checklist

Please use the following checklist to help ensure your application is complete.

Completed Application with Signature

An incomplete application will delay final approval of that application. All documents become a permanent part of your file and cannot be returned. Applications are reviewed in date order received.

Every question on the application must be answered. Be sure to answer all questions honestly. The Board of Nursing may deny your application if you provide false information on your application.

Proof of Active Certification

Your out-of-state certificate must be Clear/Active and in good standing.

Completed Confidential and Exempt from Public Records Disclosure Form

Form enclosed

Livescan

All applications received must include electronically submitted fingerprints through a Livescan provider. The Department of Health accepts electronic fingerprinting offered by Livescan providers that are approved by the Florida Department of Law Enforcement.

For a list of approved Livescan vendors BOE 'SFRVFOUMZ"TLFE2VFTUJPOTBCPVU-JWFsDBOplease visit our website at: http://www.flhealthsource.gov/background-screening/

Our current ORI number is EDOH4400Z.

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Applications and other additional documents must be mailed to:

Department of Health

Certified Nursing Assistant Registry

4052 Bald Cypress Way Bin# C-02

Tallahassee, FL 32399-3252

DH-MQA 5022 06/18, Rule 64B9-15.0035, FAC

Important Information

Application Updates

The Board office must be notified in writing of anything which changes or affects a response given in your application. Failure to do so could result in the delay of application processing or denial of your application. Examples: change of name, address, telephone number, arrests or convictions, licensure status or disciplinary action in another state, or an incorrect answer to a question.

Withdrawal of Application

If you decide to withdraw your application, you must make the request in writing. The request must be received prior to the Board considering licensure.

Criminal History

Any applicant who has ever been found guilty of, or pled guilty or no contest to/nolo contendere, any charge other than a minor traffic offense must list each offense on the application. Failure to disclose criminal history may result in denial of your application. Each application is reviewed on its own merits. Staff cannot make predeterminations in advance as laws and rules do change over time.

Violent crimes and repeat offenders are required to be presented to the Board of Nursing for review.

Applicants with criminal convictions may be required to submit the following documents:

Final Dispositions/Sanctions –Final disposition records for offenses can be obtained at the

clerk of the court in the arresting jurisdiction. If the records are not available, you must have a letter on court letterhead sent from the Clerk of the Court attesting to their unavailability.

Completion of Probation/Parole –Probation records for offenses can be obtained at the clerk of the court in the arresting jurisdiction. If the records are not available, you must have a letter on court letterhead sent from the Clerk of the Court attesting to their unavailability.

Self-Explanation –Applicants who have listed offenses on the application must submit a letter in your own words describing the circumstances of the offense.

Letters of Recommendation –Applicants who have listed offenses on the application must submit 3-5 letters of recommendation from people you have worked for or with.

Disciplinary History

Any applicant who has ever been denied, had disciplinary action, or surrendered a license to practice in any healthcare profession, in any state, jurisdiction, or country must provide a self-explanation of all occurrences of denial, disciplinary action or surrendering of a license. The State Board(s) of Nursing involved must also submit copies of the administrative complaint and final order directly to the Florida Board. Applicants are responsible to ensure that the proper documentation is sent to the Florida Board. Any action taken against your license by a state licensing board must be reported on this application.

Healthcare Fraud

IMPORTANT NOTICE: Applicants for licensure, certification or registration and candidates for examination may be excluded from licensure; certification or registration if their felony conviction falls into certain timeframes as established in Section 456.0635(2), Florida Statutes. For more information,

please visit our website at: http://floridasnursing.gov/licensing/certified-nursing-assistant-endorsement/.

DH-MQA 5022 06/18, Rule 64B9-15.0035, FAC

Florida Board of Nursing

PO Box 6330

Tallahassee, FL 32314

Phone: (850) 245-4125

Fax: (850) 617-6460

Certified Nursing Assistant Licensure by Endorsement Application

Website: www.floridasnursing.gov

Email: mqa.cna@flhealth.gov

Please complete this application in its

entirety prior to printing.

1.PERSONAL INFORMATION

Name:

 

 

 

 

 

Date of Birth:

 

 

Last/Surname

First

 

Middle

 

MM/DD/YYYY

Mailing Address: (Give the address where mail and your license should be sent)

 

 

 

 

 

 

 

 

 

 

 

 

 

Street/P.O. Box

 

 

 

 

 

Apt. No.

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

Zip

Country

Home/Cell Telephone (Input with dashes)

 

Physical Location: (Required if mailing address is a P.O. Box- This address will be posted on the Department of Health's website.)

Street

 

 

 

Apt./Suite No.

City

 

 

 

 

 

 

 

 

State

 

Zip

Country

Work/Cell Telephone (Input with dashes)

EQUAL OPPORTUNITY DATA:

We are required to ask that you furnish the following information as part of your voluntary compliance with Section 2, Uniform Guidelines on Employee Selection Procedure (1978) 43 CFR 38295 and 38296 (August 25, 1978). This information is gathered for statistical and reporting purposes only and does not in any way affect your candidacy for licensure.

SEX:

Male

Female

RACE:

White

 

 

 

 

Black or African American

 

 

 

 

Hispanic

 

 

 

 

American Indian or Alaska Native

 

 

 

 

Asian

 

 

 

 

Native Hawaiian or Other Pacific Islander

 

 

 

 

Two or More Races

DH-MQA 5022 06/18, Rule 64B9-15.0035, FAC

Page 1

NAME

Email Notification: If you want to be notified of the status of your application by email please check the "Yes" box and write your email address on the line provided below. If you choose this form of notification you will receive information

regarding your application file through email. You will be responsible for checking your email regularly and updating your email address with the Board office at: mqa.cna@flhealth.gov

I want to be notified by email

Yes

No

 

 

Email Address:

 

 

 

Under Florida law, email addresses are public records. If you do not want your e-mail address released in response to a public records request, do not provide an email address or send electronic mail to our office. Instead contact the office by phone or in writing.

2.APPLICANT BACKGROUND Attach additional sheets, if necessary

A.List any other name(s) by which you have been known in the past.

B.What name(s) did you use when you received your education?

C.What name did you use when you were first licensed?

D.Have you ever applied for licensure by examination in Florida, as a CNA? Date

Yes No

E.Have you ever applied for licensure by endorsement in Florida, as a CNA? Date

Yes No

F.Have you ever been licensed in Florida as a CNA? Date

Yes No

G.* Have you ever been denied or is there now any proceeding to deny your application for any health care license to practice in Florida or any other state, jurisdiction or country?

Yes No

*If you answer “Yes” to question G in this section, you must submit a self explanation as to why you are answering “Yes” to this question.

DH-MQA 5022 06/18, Rule 64B9-15.0035, FAC

Page 2

NAME

H. List all CNA licenses ( active, inactive or lapsed)

 

State/Country

 

 

License No.

 

License Type Date of Licensure

 

Status of License and Expiry Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The Florida Board of Nursing requires verification of licensure from from a state where you have a current active license.

3.

A.

B.

C.

CRIMINAL HISTORY

Answers to commonly asked questions can be found on our website at:

 

 

 

http://www.floridasnursing.gov/help-center/#faqs

Yes

No

Have you EVER been convicted of, or entered a plea of guilty, nolo contendere, or no

 

 

contest to, a crime in any jurisdiction other than a minor traffic offense? You must

 

 

include all misdemeanors and felonies, even if adjudication was withheld.

 

 

Reckless driving, driving while license suspended or revoked (DWLSR), driving

 

 

under the influence (DUI) or driving while impaired (DWI) are not minor traffic offenses

 

 

for purposes of this question.

Yes

No Have you EVER had any records sealed pursuant to section 943.059, F.S., or other states

 

 

applicable statute?

Yes

No

Have you EVER been adjudicated delinquent?

Failure to disclose information in this section may result in a denial of your application.

If you answered “Yes” to any of the questions above you are required to send the following items:

Self Explanation describing in detail the circumstances surrounding each offense; including dates, city and state, charges and final results.

Final Dispositions and Arrest Records for all offenses. The Clerk of the Court in the arresting jurisdiction will provide you with these documents. Unavailability of these documents must come in the form of a letter from the Clerk of the Court.

Completion of Sentence Documents. You may obtain documents from the Department

of Corrections. The report must include the start date, end date, and state that the conditions have been met.

Three (3) current (written within the last year) Letters of Recommendation.

DH-MQA 5022 06/18, Rule 64B9-15.0035, FAC

Page 3

NAME

4.

Electronic Fingerprinting:

(Required for ALL applicants)

 

 

 

 

All applicants, including out-of-state and out-of-country applicants, are required to submit their fingerprints electronically. The Department of Health accepts electronic fingerprinting offered by Livescan device providers that are approved by the Florida Department of Law Enforcement. For a list of approved Livescan vendors, please visit our website at : http://www.flhealthsource.gov/background-screening/

Typically background results submitted by Livescan are received by the Board within 24-72 hours of being processed. The Board of Nursing's ORI number is: ED0380Z. The Board cannot accept hard fingerprint cards or results. All results must be submitted electronically by the Livescan service provider.

Livescan screenings done by a Florida Police or Sheriff's Department require that you login to the FDLE Civil Applicant Payment System (CAPS) at https://caps.fdle.state.fl.us and pay a fee before results will be released to our office.

Applicants who reside in an area where no Livescan service providers are available or because of state laws prohibiting transmission of fingerprints electronically across state lines should contact a Florida Livescan service provider who has the capability to convert a traditional card (hard card) into an electronic fingerprint card.

Because the Florida Department of Health retains fingerprints on any applicant who is required to undergo a criminal history screening as of January 1, 2013, those prints are retained in the Care Provider Clearinghouse. This Clearinghouse allows for the sharing of criminal history information among specified agencies.

One of the requirements for your Livescan to be retained in the Clearinghouse is a photograph taken by the Livescan service provider at time of fingerprinting. If your Livescan is completed without a photograph, you may have to undergo additional fingerprinting in the future.

Applicants needing hard fingerprint cards can request them via email at: Mqa.BackgroundScreen@flhealth.gov

Please include your current mailing address in your request for fingerprint cards.

The Board cannot accept hard fingerprint cards or results.

For Frequently Asked Questions about Livescan and for a list of providers who offer hard card conversion see our website at:

http://www.flhealthsource.gov/background-screening/

LIVESCAN PRIVACY STATEMENT

I have been provided and read the statement from the Florida Department of Law Enforcement regarding the sharing, retention, privacy and right to challenge incorrect criminal history records and the “Privacy Statement” document from the Federal Bureau of Investigation. (Found in the forms following this application). The Board will not receive your Livescan results if you do not affirm the above statement by checking this box.

DH-MQA 5022 06/18, Rule 64B9-15.0035, FAC

Page4

NAME

5.

A.

B.

C.

DISCIPLINARY HISTORY

Yes

No

Have you ever had disciplinary action taken against your license to practice any

 

 

health care related profession by the licensing authority in Florida or in any other state,

 

 

jurisdiction or country?

Yes No Have you ever surrendered a license to practice any health care related profession in Florida or in any other state, jurisdiction or country while any such disciplinary charges were pending against you?

Yes No Do you have disciplinary action pending against any license?

Failure to disclose information in this section may result in a denial of your application.

If you answered “Yes” to any of the questions in this section, you are required to send the following items:

Self Explanation, describing in detail the circumstances surrounding the disciplinary action.

A copy of the Administrative Complaint and Final Order.

Three (3) current (written within the last year) Letters of Recommendation.

6. CRIMINAL AND MEDICAID/MEDICARE FRAUD QUESTIONS

IMPORTANT NOTICE: Applicants for licensure, certification or registration and candidates for examination may be excluded from licensure, certification or registration if their felony conviction falls into certain timeframes as established in Section 456.0635(2), Florida Statutes. If you answer “Yes” to any of the following questions, please provide a written explanation for each question including the county and state of each termination or conviction, date of each termination or conviction, and copies of supporting documentation to the address below. Supporting documentation includes court dispositions or agency orders where applicable.

1. Yes No Have you been convicted of, or entered a plea of guilty or nolo contendere, regardless of adjudication, to a felony under Chapter 409, F.S. (relating to social and economic assistance), Chapter 817, F.S. (relating to fraudulent practices), Chapter 893, F.S. (relating to drug abuse prevention and control) or a similar felony offense(s) in another state or jurisdiction?

If you responded “No”to the question above, skip to question 2.

a

.

Yes

No If “Yes” to 1, were you arrested or charged for the felony or felonies after July 1, 2009?

b.

Yes

No If “Yes” to 1, for the felonies of the first or second degree, has it been more than 15

 

 

 

years from the date of the plea, sentence and completion of any subsequent probation?

c. Yes No If “Yes” to 1, for the felonies of the third degree, has it been more than 10 years from the date of the plea, sentence and completion of any subsequent probation? (This question does not apply to felonies of the third degree under Section 893.13(6)(a), Florida Statutes).

DH-MQA 5022 06/18, Rule 64B9-15.0035, FAC

Page 5

NAME ______________________________________________

d. Yes No If “Yes” to 1, for the felonies of the third degree under Section 893.13(6)(a), Florida Statutes, has it been more than 5 years from the date of the plea, sentence and completion of any subsequent probation?

2.

e. Yes No

Yes No

If “Yes” to 1, have you successfully completed a drug court program that resulted in the plea for the felony offense being withdrawn or the charges dismissed? (If “Yes”, please provide supporting documentation).

Have you been convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, to a felony under 21 U.S.C. ss. 801-970 (relating to controlled substances) or 42 U.S.C. ss. 1395-1396 (relating to public health, welfare,

Medicare and Medicaid issues)?

3.

4.

5.

If you responded “No” to the question above, skip to question 3.

a.

Yes

No If “Yes” to 2, were you arrested or charged for the felony or felonies after July 1, 2009?

b. Yes No If “Yes” to 2, has it been more than 15 years before the date of application since the sentence and any subsequent period of probation for such conviction or plea ended?

Yes No Have you ever been terminated for cause from the Florida Medicaid Program pursuant to Section 409.913, Florida Statutes?

If you responded “No” to the question above, skip to question 4.

 

Yes

No If you have been terminated but reinstated, have you been in good standing with the

 

 

Florida Medicaid Program for the most recent five years?

Yes

No

Have you ever been terminated for cause, pursuant to the appeals procedures

 

 

established by the state, from any other state Medicaid program?

If you responded “No” to the question above, skip to question 5.

a. Yes No Have you been in good standing with a state Medicaid program for the most recent five years?

b. Yes No Did the termination occur at least 20 years before to the date of this application?

Yes No Are you currently listed on the United States Department of Health and Human Services' Office of Inspector General's List of Excluded Individuals and Entities?

DH-MQA 5022 06/18, Rule 64B9-15.0035, FAC

Page6

7.

Confidential and Exempt from Public Records Disclosure

Pursuant to Sec. 466 [42 U.S.C. 666](a), the department is required and authorized to collect Social Security Numbers relating to applications for professional licensure. Additionally, section 456.013(1)(a), Florida Statutes, authorizes the collection of Social Security Numbers as part of the general licensing provisions. This information is exempt from public records disclosure.

Last Name:

First Name:

Middle Name:

Social Security Number:

(Input with dashes)

Social Security Information - * Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless specifically required by federal statute. In this instance, Social Security numbers are mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and Section 456.013(1), 409.2577 and 409.2598, Florida Statutes. Social Security numbers are used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to ensure compliance with child support obligations. Social Security numbers must also be recorded on all professional and occupational license applications and will be used for license identification pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act. 104 Pub.L. Section 317) Clarification of the SSA process may be reviewed at www.ssa.gov or by calling 1-800-772-1213.

Board of Nursing

4052 Bald Cypress Way, Bin # C02

Tallahassee, Florida 32399-3252

Phone: (850) 245-4125 Fax: (850) 617-6460

Website: www.floridasnursing.gov

DH-MQA 5022 06/18, Rule 64B9-15.0035, FAC

Page7

NAME

8. HEALTH HISTORY (Supporting documentation should be sent directly to the board office.)

A. Yes No

B. Yes No

Do you have any condition that currently impairs your ability to practice your profession with reasonable skill and safety?

Are you using medications, other drugs, narcotics, or intoxicating chemicals that impair your ability to practice your profession with reasonable skill and safety?

.

If you answered “Yes” to any of the questions in this section, you are required to send the following items:

Please provide a letter from a licensed health practitioner, who is qualified by skill and training to address your condition, which explains the impact your condition may have on your ability to practice your profession with reasonable skill and safety, and stating either that you are safe to practice your profession without restriction or indicating what restrictions are necessary. If necessary, you may

attach additional sheets.

Documentation must be current within the last year.

If you fail to disclose the information requested in this section, your application may be denied.

Self Explanation, explaining the medical condition(s) or occurrence(s) and current status.

DH-MQA 5022 06/18, Rule 64B9-15.0035, FAC

Page8

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filling in cna endorsement application fl step 1

You have to fill out the EQUAL OPPORTUNITY DATA We are, SEX, Male, Female, RACE, White Black or African American, DHMQA Rule B FAC, and Page box with the required particulars.

Entering details in cna endorsement application fl part 2

Determine the crucial details in the NAME, If you want to be notified of the, mqacnaflhealthgov, I want to be notified by email, Yes, Email Address, Under Florida law email addresses, APPLICANT BACKGROUND, Attach additional sheets if, A List any other names by which, B What names did you use when you, C What name did you use when you, Have you ever applied for, and Date part.

step 3 to entering details in cna endorsement application fl

Describe the rights and responsibilities of the parties within the field Yes, Have you ever applied for, Date, Yes, F Have you ever been licensed in, Yes, Have you ever been denied or is, Yes, and If you answer Yes to question G in.

Finishing cna endorsement application fl part 4

End by looking at the following areas and preparing them accordingly: H List all CNA licenses, active inactive or lapsed, NAME, StateCountry, License No, License Type, Date of Licensure, Status of License and Expiry Date, The Florida Board of Nursing, a state where you have a current, CRIMINAL HISTORY Answers to, Yes, and Have you EVER been convicted of or.

Filling out cna endorsement application fl stage 5

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