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AHCA Form

AHCA Form

ATTESTATION OF COMPLIANCE

with Background Screening Requirements

Authority: This form may be used by all employees to comply with:

  • the attestation requirements of section 435.05(2), Florida Statutes, which state that every employee required to undergo Level 2 background screening must attest, subject to penalty of perjury, to meeting the requirements for qualifying for employment pursuant to this chapter and agreeing to inform the employer immediately if arrested for any of the disqualifying offenses while employed by the employer; AND
  • the proof of screening within the previous 5 years in section 408.809(2), Florida Statutes which require proof of compliance with level 2 screening standards that have been screened through the Care Provider Background Screening Clearinghouse created under Section 435.12, F.S., or screened within the previous 5 years by the Agency, Department of Health, Department of Elder Affairs, the Agency for Persons with Disabilities, Department of Children and Families, or the Department of Financial Services.

This form must be maintained in the employee’s personnel file. If this form is used as proof of screening for an administrator or chief financial officer to satisfy the requirements of an application for a health care provider license, please attach a copy of the screening results and submit with the licensure application.

Employee/Contractor Name:
Health Care Provider/ Employer Name: Essential Healthcare Services, Inc.
Address of Health Care Provider: 13506 N. Rome Avenue #102 Tampa, FL 33613
I hereby attest to meeting the requirements for employment and that I have not been arrested for and been found guilty of, regardless of adjudication, or entered a plea of nolo contendere, or guilty to any offense.
Criminal offenses found in section 435.04, F.S.
(a) Section 393.135 relating to sexual misconduct.
(b) Section 394.4593 relating to sexual misconduct with mental health patients.
(c) Section 415.111 relating to adult abuse.
(d) Section 777.04 relating to attempts and conspiracy.
(e) Section 782.04 relating to murder.
(f) Section 782.07 relating to manslaughter.
(g) Section 782.071 relating to vehicular homicide.
(h) Section 782.09 relating to killing of an unborn child.
(i) Chapter 784 relating to assault and battery.
(j) Section 784.011 relating to assault if victim was a minor.
(k) Section 784.03 relating to battery if victim was a minor.
(l) Section 787.01 relating to kidnapping.
Legal Sections
(m) Section 787.02, relating to false imprisonment.
(n) Section 787.025, relating to luring or enticing a child.
(o) Section 787.04(2), relating to taking, enticing, or removing a child beyond the state limits with criminal intent pending custody proceedings.
(p) Section 787.04(3), relates to carrying a child beyond the state lines with criminal intent to avoid producing a child at a custody hearing.
(q) Section 790.115(1), relating to exhibiting firearms or weapons within 1,000 feet of a school.
(r) Section 790.115(2)(b), relating to possessing an electric weapon or device on school property.
(s) Section 794.011, relating to sexual battery.
(t) Former s. 794.041, relating to prohibited acts of persons in familial authority.
(u) Section 794.05, relating to unlawful sexual activity with certain minors.
(v) Chapter 796, relating to prostitution.
(w) Section 798.02, relating to lewd and lascivious behavior.
(x) Chapter 800, relating to lewdness and indecent exposure.
(y) Section 806.01, relating to arson.
(z) Section 810.02, relating to burglary.
(aa) Section 810.14, relating to voyeurism, if the offense is a felony.
(bb) Section 810.145, relating to video voyeurism.
(cc) Chapter 812, relating to theft and robbery.
(dd) Section 817.563, relating to fraudulent sale of controlled substances.
(ee) Section 825.102, relating to abuse of an elderly person.
(ff) Section 825.1025, relating to lewd offenses committed in presence of elderly.
(gg) Section 825.103, relating to exploitation of elderly persons.
(hh) Section 826.04, relating to incest.
(ii) Section 827.03, relating to child abuse.
(jj) Section 827.04, relating to contributing to delinquency of a child.
(kk) Former s. 827.05, relating to negligent treatment of children.
(ll) Section 827.071, relating to sexual performance by a child.
(mm) Section 843.01, relating to resisting arrest with violence.
(nn) Section 843.025, relating to depriving law enforcement of communication.
(oo) Section 843.12, relating to aiding in an escape.
(pp) Section 843.13, relating to aiding escape of juvenile inmates.
(qq) Chapter 847, relating to obscene literature.
(rr) Section 874.05(1), relating to encouraging criminal gang.
(ss) Chapter 893, relating to drug abuse prevention.
(tt) Section 916.1075, relating to sexual misconduct with forensic clients.
(uu) Section 944.35(3), relating to cruel treatment on inmate.
(vv) Section 944.40, relating to escape.
(ww) Section 944.46, relating to harboring escaped prisoner.
(xx) Section 944.47, relating to contraband in correctional facility.
(yy) Section 985.701, relating to sexual misconduct in juvenile justice.
(zz) Section 985.711, relating to contraband in detention facilities.
Criminal offenses found in section 408.809(4), F.S.
(a) Any authorizing statutes, if the offense was a felony. (m) Section 817.60, relating to obtaining a credit card through fraudulent means.
(b) This chapter, if the offense was a felony. (n) Section 817.61, relating to fraudulent use of credit cards, if the offense was a felony.
(c) Section 409.920, relating to Medicaid provider fraud. (o) Section 831.01, relating to forgery.
(d) Section 409.9201, relating to Medicaid fraud. (p) Section 831.02, relating to uttering forged instruments.
(e) Section 741.28, relating to domestic violence. (q) Section 831.07, relating to forging bank bills, checks, drafts, or promissory notes.
(f) Section 777.04, relating to attempts, solicitation, and conspiracy. (r) Section 831.09, relating to uttering forged bank bills, checks, drafts, or promissory notes.
(g) Section 817.034, relating to fraudulent acts through mail, wire, radio, electromagnetic, photoelectronic, or photooptical systems. (s) Section 831.30, relating to fraud in obtaining medicinal drugs.
(h) Section 817.234, relating to false and fraudulent insurance claims. (t) Section 831.31, relating to sale or manufacture of counterfeit controlled substances.
(i) Section 817.481, relating to obtaining goods by using a false or expired credit card. (u) Section 895.03, relating to racketeering and collection of unlawful debts.
(j) Section 817.50, relating to fraudulently obtaining goods or services from a health care provider. (v) Section 896.101, relating to the Florida Money Laundering Act.
(k) Section 817.505, relating to patient brokering.
(l) Section 817.568, relating to criminal use of personal identification information.
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**A copy of the Exemption from Disqualification decision letter must be attached** Attestation Under penalty of perjury, I, __________________________, hereby swear or affirm that I meet the requirements for qualifying for employment in regard to the background screening standards set forth in Chapter 435 and section 408.809, F.S. In addition, I agree to immediately inform my employer if arrested or convicted of any of the disqualifying offenses while employed by any health care provider licensed pursuant to Chapter 408, Part II F.S.
Clear Signature
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