Florida Home Medical Equipment Provider AHCA Form 3110-1020, Request for Change of Name and or Addre
Form Template
Under the authority of Florida Statutes and Florida Administrative Code (F.A.C.), the Florida Home Medical Equipment Provider AHCA Form 3110-1020, Request for Change of Name and or Address app can be submitted for a new license due to the pending change of name and/or address of a home medical equipment (HME) provider.
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F.A.C., requires any request to change the address of record of a home medical equipment provider license be received by the Agency 21 to 120 days in advance of the requested effective date. All other requests to amend a license including change of name must be received 60 to 120 days in advance. The app makes it simple to submit a change request.
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