How to Fill Out AHCA Form 2200-0003: Notarize, Submit, and Maintain

To fill out the AHCA background screening affidavit, confirm in the Care Provider Background Screening Clearinghouse that every person at your facility who requires a Level 2 screening shows a cleared status, enter your facility name and AHCA file number on the current form, and then sign it in front of a notary public before uploading it with your licensing application. The form is a sworn statement, so the signature is the legally meaningful act and the Clearinghouse check is what makes that signature truthful.

One housekeeping note before you start. Providers often search for this document by its older designation, AHCA Form 2200-0003. AHCA periodically renumbers its forms, and the current version of the background screening attestation is listed as AHCA Form 3100-0008 on the agency’s applications-for-licensure page under “Forms for All Provider Types.”¹ Download it fresh each time rather than reusing a saved copy.

What to Verify Before You Sign

The affidavit is a sworn attestation that every person at your facility who is required to be screened has been screened and found eligible. Florida law identifies that group specifically: the licensee, the administrator or equivalent, the financial officer, anyone with a controlling interest, and any employee or contractor who provides direct care or has access to client funds, personal property, or living areas.²

Signing without checking each of those people against the Clearinghouse Results Website is the main way providers get themselves in trouble on this form. Log in to the CRW portal and open the Employee/Contractor Roster tab. Every person connected to your facility appears there with a current screening status. If any required person shows an incomplete, pending, or ineligible result, resolve it before you touch the affidavit. Florida law requires employers to maintain employment status records in the Clearinghouse and report changes within five business days, so a well-maintained roster makes the verification almost mechanical.³

If your facility doesn’t yet have CRW access, register through the portal: create an account with a valid email, then request access for your provider by selecting the state agency, choosing your provider type, and searching for your facility name. AHCA reviews the request and emails confirmation once access is approved.⁴

Timing matters here. A Level 2 screening takes about five to seven business days to process once the Florida Department of Law Enforcement receives the results.⁵ Initiating screenings on new hires the same week you plan to file the application is the most common reason providers can’t truthfully sign on schedule.

One boundary worth naming. If an employee has a disqualifying offense but has applied to AHCA for an exemption from disqualification, you cannot certify them as cleared on this affidavit until AHCA has actually granted the exemption.⁶ A pending application does not count.

Filling In the Form

Gather four things before you open the PDF:

The full legal name of the facility exactly as it appears on your AHCA license or application.
Your AHCA file number, which you can find on prior licensing correspondence or in the Online Licensing System.
The full legal name and title of the person who will sign. If the licensee is an individual, that’s the licensee; otherwise it’s an authorized representative such as the administrator or compliance officer.
Confirmation from the Clearinghouse roster that every screening-required person is cleared.

At the top of the form, enter the facility name and AHCA file number. The body contains affirmation statements referencing Section 408.809, Florida Statutes, and Chapter 435. Check each applicable box to confirm that everyone required to undergo Level 2 screening has been screened and found eligible.

Do not sign yet. The signature has to be applied in the presence of a notary.

Accuracy on the identifiers is non-negotiable. Any mismatch between the facility name on the affidavit and the name on file with AHCA, or a wrong file number, triggers a notice of omission that stalls the whole licensing package.

Getting the Signature Notarized

Because this is a sworn statement, Florida law requires notarization. The signer appears before a notary public, either in person or through an authorized online notarization platform, and signs while the notary watches.⁷ Bring a current government-issued photo ID; the notary will use it to verify identity.

After witnessing the signature, the notary applies a rubber-stamp seal and completes a notarial certificate indicating the statement was “sworn to” or “affirmed.” The seal must include the words “Notary Public–State of Florida,” the notary’s name, commission number, and commission expiration date.⁸ A missing or illegible seal, or a certificate that omits any of these elements, will get the affidavit rejected.

Florida caps the fee at $10 per notarial act for in-person notarization and $25 for a remote online notarial act.⁷ Many banks and UPS locations offer notary services, and some AHCA-regulated facilities keep a notary on staff.

Submitting the Affidavit

The affidavit goes in with your larger licensing application package. AHCA directs providers to use the Online Licensing System for both initial and renewal applications, and renewals must go through the online system per Rule 59A-35.060.¹ Upload a scanned copy of the signed and notarized affidavit as an attachment inside the system.

If you’re filing an initial application by mail, the address is AHCA headquarters at 2727 Mahan Drive in Tallahassee. The mail stop code varies by provider type, so check the application checklist for your facility category. Use certified mail or a tracked service for proof of receipt. Whichever method you choose, the application fee must accompany the application or AHCA will return it.

What Happens After You File

Once AHCA receives a complete application package, the agency has 30 days to notify you of any errors or omissions and 60 days to approve or deny the application.⁹ If the agency finds a problem with your affidavit, a missing notary seal, a wrong file number, a name mismatch, it issues a notice of omission and the clock resets when you send corrected documents. A clean submission moves through far faster than one that triggers back-and-forth.

Keeping the Affidavit Truthful Between Renewals

You will sign a fresh affidavit at every license renewal, and the facts you swear to can shift between filings. Two rules do most of the work in making an attestation false without anyone noticing.

First, Level 2 screenings expire. Florida law requires fingerprints to be resubmitted every five years, and employees whose last screening fell between July 2021 and June 2022 must be rescreened by June 30, 2026.³ The retention window to keep the existing record active opens 75 days before the fingerprint expiration date and closes 15 days before it. Miss the window and the employee needs a brand-new screening rather than a retention renewal.¹⁰

Second, any employee with a break in service of more than 90 days from a screened position must undergo a new national screening before returning to work.³ A returning staff member whose paperwork wasn’t refreshed will show as ineligible on the Clearinghouse roster, and signing the affidavit while they’re on your schedule is a problem.

Treat the Clearinghouse roster as a living document, not something you review the week before an application is due. That is what makes signing the next affidavit a formality instead of a scramble.

1
Florida Agency for Health Care Administration. HQA Applications for Licensure
2
Florida Statutes. Florida Code 408.809 – Background Screening; Prohibited Offenses
3
Florida Senate. Florida Code 435.12 – Care Provider Background Screening Clearinghouse
4
Agency for Health Care Administration. Care Provider Background Screening Clearinghouse AHCA Clearinghouse Results Website Instruction Guide
5
Florida Agency for Health Care Administration. Screening Information
6
Agency for Health Care Administration. Frequently Asked Questions – Exemption from Disqualification Process
7
Florida Senate. Florida Code 117.05 – Use of Notary Commission; Unlawful Use; Notary Fee; Seal; Duties
8
Florida Department of State. Notary Commissions and Apostille/Certification Sections – Sample Notarial Statements
9
Agency for Health Care Administration. Online Licensure Renewal Process Audit
10
FL HealthSource. Background Screening – Initiate a Screening