AHCA Attestation Form 3100-0008: Who Signs It and Where It Goes

AHCA Form 3100-0008 is a one-page sworn statement that each employee or contractor at a Florida healthcare facility signs to confirm they meet the state’s Level 2 background screening requirements.¹ You fill it out yourself, sign under penalty of perjury, and hand it to your employer, who files it in your personnel record. The facility does not submit it to the Agency for Health Care Administration.²

Who Has to Sign One

Florida Statute 408.809 lists the people at an AHCA-regulated provider who need Level 2 screening and therefore a completed Form 3100-0008 on file. That includes the licensee if the licensee is an individual, the administrator, the financial officer, anyone with a controlling interest, direct-care staff, and employees or contractors with access to client funds, personal property, or living areas (contractors at the 20-hours-per-week threshold).³ These rules apply at nursing homes, assisted living facilities, home health agencies, hospices, and healthcare clinics licensed under Chapter 408, Part II.

Some volunteer roles are exempt from fingerprinting when the hours are limited and supervision is direct and constant, but the specifics vary by provider type. If a volunteer position at your facility sits near that line, check the authorizing statute for your license category.

Where to Get the Current Form

Use the July 2024 version. You can download it from AHCA’s background screening page or through the Florida Administrative Code reference link.¹ Before you start, get the legal name and street address of the facility that employs you; those are the only facts not already in your head.

Filling Out the Form

The required fields are brief and literal:

Health Care Provider/Employer Name: the legal name of the licensed facility.
Address of Health Care Provider: the facility’s physical address.
Employee/Contractor Name: your full legal name.
Title: your job title or role.
Date: the date you sign.
Employee/Contractor Signature: your handwritten signature.

That is the entire mandatory portion. Everything else on the page is conditional.

The Prior Screening Section (Optional)

The form includes a section you can use only if two things are true: you completed a Level 2 screening within the last five years through the Department of Financial Services, and you have not had a break of more than 90 days from a screened position. If both apply, write in the purpose of that prior screening and attach a copy of the screening results to the form. That lets your prior screening cover you instead of a fresh fingerprint submission.²

The 90-day rule is strict. Under Florida Statute 435.12, more than 90 days away from a screened position requires a new national screening before you return to one.⁴ If that applies to you, skip this section and go through the full screening process; the Clearinghouse will handle it as a resubmission of your retained fingerprints, but the check still has to run before you can start work.

The Exemption From Disqualification Checkboxes

Near the bottom of the form sit two checkboxes for people who have been granted an exemption from disqualification. One is for exemptions granted by AHCA; the other is for exemptions granted by the Florida Department of Health. If one applies to you, check the correct box, enter the date of the decision, and attach the exemption decision letter. The checkbox alone, without the letter attached, is not enough.²

Which agency grants the exemption depends on your license status. AHCA handles exemption decisions for people who do not hold an active professional license from the Department of Health, or who hold one but are not working within its scope. If you do hold an active license and are working within that scope, the appropriate Department of Health regulatory board decides.³

Where the Signed Form Goes

Give the completed form to your employer. The employer keeps it in your personnel file and does not send it to AHCA.² State surveyors can ask to see it during inspections, so facilities need it accessible. A missing attestation is a compliance gap that can draw a citation.

There is one exception to the keep-it-on-site rule. When the form documents screening for an administrator or chief financial officer as part of a healthcare provider licensure application, the provider attaches a copy of the screening results to the form and submits both with the licensure application package.²

What You Are Swearing To

By signing, you swear under penalty of perjury that you meet the qualifications for employment under Chapter 435 and Section 408.809 of the Florida Statutes. You also agree to immediately notify your employer if you are arrested for a disqualifying offense while working at any provider licensed under Chapter 408, Part II.² The arrest-reporting obligation runs for the life of your employment, not just the moment you sign.⁵

The penalties for a false attestation are real. Knowingly making a false declaration under penalty of perjury is a third-degree felony under Florida Statute 92.525, punishable by up to five years in prison.⁶ Florida Statute 435.11 adds a separate first-degree misdemeanor for willfully using false statements or misrepresentation to conceal material facts about qualifications for a position of special trust, carrying up to one year in jail and a fine of up to $1,000.⁷ Signing while knowing you have an unresolved disqualifying offense exposes you to both.

The Attestation Is Not the Screening

Signing Form 3100-0008 does not screen you. It is your sworn confirmation that the screening already behind you came out clean (or that you have a valid exemption or qualifying prior screening). The actual Level 2 check is a fingerprint-based criminal history run through the Florida Department of Law Enforcement and the FBI, submitted electronically through the Care Provider Background Screening Clearinghouse.⁴ Your employer initiates that process; you complete the Livescan appointment it generates. The attestation is the paperwork that memorializes the result in your file.

1
Florida Administrative Code. Fla. Admin. Code Ann. R. 59A-35.090 – Background Screening
2
Agency for Health Care Administration. AHCA Form 3100-0008 – Attestation of Compliance with Background Screening Requirements
3
Florida Senate. Florida Code 408 – Section 809
4
Florida Senate. Florida Code 435 – Section 12
5
Florida Statutes. Florida Code 435 – Section 05
6
Florida Statutes. Florida Code 92 – Section 525
7
Florida Statutes. Florida Code Chapter 435 – Employment Screening