The CNA License to Florida form is an application required for individuals seeking to obtain certification as a Certified Nursing Assistant in Florida. This form must be filled out completely and accurately to ensure timely processing. If you are ready to begin this important step in your career, please fill out the form by clicking the button below.
When applying for a Certified Nursing Assistant (CNA) license in Florida, completing the CNA License To Florida form is a critical step in the process. This form serves as a comprehensive application that requires applicants to provide personal information, proof of active certification, and details about their criminal and disciplinary history. It includes a checklist to help ensure that all necessary components are included, such as a completed application with a signature, a Livescan fingerprint submission, and a Confidential and Exempt from Public Records Disclosure Form. Each question on the application must be answered honestly, as providing false information can lead to denial. Additionally, applicants must be prepared to submit documentation regarding any criminal history or disciplinary actions from previous licenses. It is essential to keep the Board of Nursing informed of any changes that may affect the application. By understanding the requirements and ensuring all information is accurate and complete, applicants can navigate the licensing process more smoothly.
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/.
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: [email protected]
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
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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: [email protected]
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.
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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.
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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: [email protected]
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.
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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?
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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
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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.
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Completing the CNA License to Florida form requires careful attention to detail. Each section must be filled out accurately to avoid delays in processing. After submitting the application, the Board of Nursing will review it in the order it was received. If any additional information is needed, the Board will reach out to you. Following the steps outlined below will help ensure your application is complete.
The application checklist is a helpful tool to ensure that your application for the Certified Nursing Assistant (CNA) license is complete. It includes several key components that must be fulfilled:
Make sure to answer every question honestly, as any false information could lead to denial of your application.
Once you have completed your application and gathered all necessary documents, you must mail them to the following address:
Department of Health Certified Nursing Assistant Registry 4052 Bald Cypress Way Bin# C-02 Tallahassee, FL 32399-3252
Ensure that you send everything together, as incomplete submissions can delay processing.
If there are any changes to the information provided in your application, such as a change of name, address, or any legal matters, you must notify the Board office in writing. It is important to do this promptly, as failing to update your information can result in delays or even denial of your application.
If you have ever been found guilty of, or pled guilty to, any charge other than a minor traffic offense, you need to disclose this information on your application. You will be required to submit additional documents, including:
Each application is reviewed individually, so it's crucial to provide all requested information to avoid complications.
Yes, you can withdraw your application. However, this must be done in writing and received by the Board before they consider your licensure. If you decide to withdraw, make sure to do it as soon as possible to avoid unnecessary processing time.
Leaving Questions Blank: Every question on the application must be answered. Failing to provide a response can lead to delays or denials.
Providing False Information: Honesty is crucial. If the Board of Nursing discovers any false information, it may deny the application.
Not Including Proof of Certification: Applicants must submit proof of an active certification from another state. An inactive or expired certificate will not suffice.
Skipping the Livescan Requirement: All applicants must include electronically submitted fingerprints. Failing to do so can halt the application process.
Neglecting to Update Personal Information: Changes in name, address, or any other relevant information must be communicated in writing to avoid processing delays.
Not Disclosing Criminal History: Any past criminal convictions, even minor ones, must be listed. Omitting this information can result in denial.
Ignoring Disciplinary Actions: If there has been any disciplinary action against a healthcare license, it must be reported. This includes denials or license surrenders.
Failing to Submit Required Documents: Applicants must provide necessary documentation for any criminal history or disciplinary actions. This includes letters of recommendation and final disposition records.
Inadequate Self-Explanations: If answering "yes" to certain questions, a detailed self-explanation is required. Vague or incomplete explanations can lead to further scrutiny.
Not Following Submission Guidelines: Applications must be mailed to the correct address. Sending to the wrong location can delay processing significantly.
When applying for a Certified Nursing Assistant (CNA) license in Florida, several additional forms and documents may be necessary to ensure a smooth application process. Below is a list of commonly used documents that accompany the CNA License application. Each plays a vital role in verifying eligibility and maintaining compliance with state regulations.
Completing these additional forms and providing the necessary documentation will help facilitate the review of your CNA application. Ensuring that every requirement is met can lead to a more efficient licensing process, allowing you to begin your career in healthcare sooner.
The Certified Nursing Assistant (CNA) License Application is similar to the Nurse Licensure Application. Both documents require applicants to provide personal information, proof of education, and verification of prior licenses. Additionally, both forms necessitate the disclosure of any criminal history, ensuring that the applicant meets the ethical and legal standards required to practice in the healthcare field. Just as the CNA application emphasizes the importance of honesty, the Nurse Licensure Application also stresses the need for truthful responses to avoid potential denial of licensure.
Another comparable document is the Medical Assistant Certification Application. Like the CNA application, this form requires proof of training and certification from an accredited program. Applicants must also submit fingerprints for background checks, similar to the Livescan requirement in the CNA process. Both applications aim to ensure that the applicant is qualified and has no disqualifying criminal history, thereby safeguarding patient care and trust in the healthcare system.
The Licensed Practical Nurse (LPN) Application shares similarities with the CNA License Application, particularly in the need for a completed application and proof of active certification. Both forms require the applicant to detail their educational background and any disciplinary actions taken against previous licenses. This ensures that only qualified individuals are permitted to provide care, reflecting the shared responsibility of maintaining high standards in the nursing profession.
The Registered Nurse (RN) License Application also mirrors the CNA application in its structure and requirements. Both documents require applicants to provide comprehensive personal information and disclose any past criminal history. Additionally, both applications necessitate the submission of official transcripts and verification from previous licensing boards, ensuring that applicants meet the necessary qualifications to practice safely and effectively.
The Occupational Therapy Assistant (OTA) Application is another document that resembles the CNA License Application. Both forms require proof of education from accredited programs and the completion of background checks. Additionally, applicants must provide information regarding any past criminal convictions, emphasizing the importance of ethical conduct in healthcare roles. This parallel underscores the shared goal of protecting patient welfare across various healthcare professions.
The Physical Therapist Assistant (PTA) Application is similar to the CNA License Application in that both require detailed personal information and verification of education. Applicants for both licenses must also disclose any criminal history and provide letters of recommendation, reflecting the importance of professional integrity in healthcare. This ensures that only those who meet the ethical standards are allowed to practice.
The Home Health Aide (HHA) Certification Application shares many characteristics with the CNA License Application. Both require applicants to submit proof of training and pass background checks. Additionally, both applications emphasize the need for honesty regarding any past criminal history or disciplinary actions, reinforcing the importance of trustworthiness in providing care to vulnerable populations.
The Pharmacy Technician Certification Application is another document that resembles the CNA License Application. Both require applicants to provide personal information, proof of education, and background checks. Furthermore, applicants must disclose any criminal history, ensuring that individuals who may pose a risk to patient safety are identified and appropriately managed. This shared requirement highlights the critical nature of ethical practice in all healthcare roles.
The Emergency Medical Technician (EMT) Certification Application is similar to the CNA License Application in its focus on ensuring the applicant’s qualifications and background. Both applications require proof of training and completion of background checks. Additionally, applicants must disclose any past criminal convictions, which is crucial for maintaining the integrity and safety of emergency medical services.
Lastly, the Respiratory Therapist License Application shares similarities with the CNA License Application, particularly in the need for comprehensive personal and educational information. Both documents require background checks and disclosure of any criminal history, emphasizing the importance of ethical behavior in healthcare professions. This ensures that only qualified individuals are entrusted with patient care responsibilities.
When filling out the CNA License to Florida form, it’s essential to approach the process with care. Here are eight important dos and don'ts to keep in mind:
By following these guidelines, you can help ensure that your application is processed smoothly and efficiently.
All applications must be completed and signed. An unsigned application will be considered incomplete, leading to delays.
While criminal history must be disclosed, each application is reviewed individually. Disclosing offenses is crucial for consideration.
Submitting fingerprints through an approved Livescan provider is mandatory. This step is essential for processing the application.
Withdrawal requests must be made in writing before the Board considers your application. Failing to follow this process can lead to complications.
Providing false information can lead to denial of your application. Honesty is essential throughout the process.
Any changes affecting your application must be reported in writing. This includes changes in name, address, or criminal history.
If you have a criminal history, you must submit 3-5 letters of recommendation. This documentation is crucial for your application.
When filling out the CNA License to Florida form, consider the following key takeaways to ensure a smooth application process:
By following these guidelines, you can enhance your chances of a successful application for your CNA license in Florida.