Agency Administrator Appointment Form - Florida Department 2025

1. Click ‘Get Form’ to open the Agency Administrator Appointment Form in the editor.
2. Begin by filling out the 'Agency Name' field. Ensure you provide the full name of your agency.
3. Indicate whether this is a new appointment or a removal by checking the appropriate box.
4. Complete the 'Applicant Information' section, including your full name, title, employee ID number, telephone number, and email address. Remember to print or type clearly.
5. Initial each statement confirming the accuracy of your information and understanding of confidentiality obligations regarding protected health information.
6. Fill out the 'Agency Head or Designee Information' section with their name, title, phone number, and email address.
7. Finally, ensure both you and the agency head sign and date the form electronically using the specified format before submitting it.

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