The CNA License to Florida form is an essential application for individuals seeking to obtain certification as a Certified Nursing Assistant in the state of Florida. Completing this form accurately is crucial, as it serves as the foundation for your licensure process. To ensure a smooth application experience, please follow the guidelines and checklist provided in the form.
Ready to take the next step? Fill out the form by clicking the button below.
Obtaining a Certified Nursing Assistant (CNA) license in Florida involves a detailed application process, encapsulated in the CNA License to Florida form. This form serves as a critical gateway for individuals seeking to practice as CNAs in the state. It requires applicants to complete a checklist that ensures all necessary components are submitted. A completed application must include a signature and answers to every question, as omissions can lead to delays or denials. Applicants must also provide proof of active certification from another state, ensuring that their credentials are in good standing. Additionally, the form mandates the submission of electronically captured fingerprints via a Livescan provider, a requirement designed to enhance security and streamline background checks. Transparency is paramount; applicants must disclose any criminal history and disciplinary actions from previous licenses, as failure to do so could result in serious consequences. The form also includes sections for personal information, background checks, and optional email notifications regarding application status. Each application is reviewed in the order it is received, emphasizing the importance of thoroughness and accuracy in the submission process. Understanding these requirements is essential for a smooth application experience.
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.
IUUQ GMPSJEBTOVSTJOHHPWGPSNTFMFDUSPOJDGJOHFSQSJOUJOHGPSNDOBCZFYBNQEG
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/.
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.
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
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
F.Have you ever been licensed in Florida as a CNA? Date
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?
*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.
Page 2
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
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.
No Have you EVER had any records sealed pursuant to section 943.059, F.S., or other states
applicable statute?
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.
Page 3
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.
Page4
5.
DISCIPLINARY HISTORY
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?
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.
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
.
No If “Yes” to 1, were you arrested or charged for the felony or felonies after July 1, 2009?
b.
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).
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
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)?
If you responded “No” to the question above, skip to question 3.
a.
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.
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?
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?
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
Page7
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?
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.
Page8
Completing the CNA License application form for Florida requires careful attention to detail. Each step must be followed precisely to ensure that the application is processed without delays. The form collects essential personal information, background details, and documentation necessary for licensure.
Once the application is submitted, it will be reviewed in the order received. It is important to monitor any updates or requests for additional information from the Board of Nursing. Keeping communication open and timely will facilitate the processing of your application.
What is the application checklist for obtaining a CNA license in Florida?
To ensure your application is complete, follow the checklist provided by the Florida Board of Nursing. First, submit a completed application with your signature. Make sure every question is answered honestly, as any false information may lead to denial. You must also provide proof of active certification from your out-of-state license. Additionally, include a completed Confidential and Exempt from Public Records Disclosure Form and submit your fingerprints electronically through an approved Livescan provider. Lastly, mail all documents to the Department of Health Certified Nursing Assistant Registry in Tallahassee.
What happens if I need to update my application information?
If there are any changes affecting your application, such as a change of name, address, or any criminal history, you must notify the Board office in writing. Failing to do so can delay the processing of your application or even result in denial. It's crucial to keep your information accurate and up-to-date to avoid complications.
What should I do if I have a criminal history?
If you have ever been found guilty of or pled guilty to any crime, you must disclose this on your application. This includes misdemeanors and felonies, except for minor traffic offenses. You will need to provide a self-explanation detailing the circumstances of each offense, along with any final disposition records. Additionally, letters of recommendation from past employers may be required. Each application is considered on its own merits, so full disclosure is essential.
How can I withdraw my application if I change my mind?
If you decide to withdraw your application, you must submit a written request. This request should be made before the Board begins considering your licensure. Once your application is in process, withdrawing may become more complicated, so it's best to act quickly if you wish to cancel.
Filling out the CNA License to Florida form can be a straightforward process, but many applicants make common mistakes that can delay their application. One of the biggest pitfalls is submitting an incomplete application. Each question on the form must be answered, and leaving any section blank can lead to unnecessary delays. It's essential to read through the application checklist carefully to ensure that all required information is provided.
Another frequent error is providing inaccurate information. Honesty is crucial when answering questions, especially regarding criminal history and previous licensure. If any false information is detected, the Board of Nursing may deny your application. Be sure to double-check your answers before submitting the form to avoid this issue.
Many applicants also overlook the requirement for proof of active certification. If you hold an out-of-state certificate, it must be clear and in good standing. Failing to provide this documentation can result in a delay or denial of your application. Always ensure that your certification is current and meets Florida's standards before applying.
Another mistake involves the Livescan fingerprinting process. All applications must include electronically submitted fingerprints from an approved Livescan provider. Applicants sometimes forget to complete this step, which can halt the entire application process. Make sure to schedule your Livescan appointment early to avoid any last-minute issues.
Not updating the Board office about any changes is another common oversight. If your personal information changes—like your name, address, or phone number—it's your responsibility to notify the Board in writing. Failing to do so could lead to delays or even denial of your application.
Finally, many applicants neglect to include necessary documentation related to their criminal history or disciplinary actions. If you have ever been found guilty of a crime or faced disciplinary action in another state, you must disclose this information and provide appropriate documentation. This includes final dispositions and letters of recommendation. Ignoring this requirement can significantly impact your chances of obtaining your CNA license.
When applying for a Certified Nursing Assistant (CNA) license in Florida, several additional forms and documents may be required to ensure a complete application. Each of these documents serves a specific purpose in the licensing process and helps the Board of Nursing evaluate the applicant's qualifications and background.
Gathering these documents can help streamline the application process and ensure that all necessary information is provided to the Board of Nursing. It is essential to be thorough and honest in completing each form to avoid potential delays or complications in obtaining licensure.
When filling out the CNA License to Florida form, it's essential to follow specific guidelines to ensure a smooth application process. Here’s a helpful list of what to do and what to avoid:
Following these guidelines will help you navigate the application process more effectively and increase your chances of success.
When applying for a Certified Nursing Assistant (CNA) license in Florida, several misconceptions can lead to confusion or delays in the application process. Here are seven common misunderstandings:
Understanding these misconceptions can help streamline the application process and ensure a smoother path to obtaining your CNA license in Florida.
When filling out the CNA License to Florida form, consider the following key takeaways: