Leased Nursing Home Surety Bond Form - Agency For Health Care Administration printable pdf download

AGENCY FOR HEALTH CARE ADMINISTRATION

LEASED NURSING HOME SURETY BOND

Bond Number_____________________

Known to all persons by these present that _____________________________________ as

(nursing home)

principal and ____________________________________________ a corporation organized and

(bonding company name)

existing under the laws of the State of _________________________ with a place of business at

__________________________________________________________________________________________

(street address)

(county)

(city/state/zip)

and licensed to transact a surety business in the State of Florida, as surety are indebted to the State of Florida,

Agency for Health Administration in the penal sum of _______________________________________________

(obligee)

__________________________________($_____________________), for which payment principal and surety bind

ourselves and our legal representatives and successors, jointly and severally.

The condition of this obligation is that principal is a nursing facility licensed under Chapter 400, Florida Statutes, (F.S.),

and is required by the Agency, pursuant to Section 400.179(5)(d), F.S., to acquire, maintain, and provide proof to the

Agency of a bond with a term of 30 months, in an amount not less than the total of 3 months Medicaid payments to the

facility computed on the basis of the preceding 12 month average Medicaid payments to the facility.

If principal and all of principal’s agents and employees faithfully conform to and abide by the provisions of all the above

statute, implementing regulations and bulletins, together with all amendatory and supplementary acts, now and hereafter

enacted, and if principal honestly and faithfully applies funds received, and faithfully and honestly performs all

obligations and undertakings made pursuant to the provisions of such statute in the conduct of providing Medicaid

services by principal and by principal’s agent and employees, then this obligation shall be null and void; otherwise it shall

be in full force and effect.

1. The total aggregate liability of surety shall be limited to the sum of ________________________________________

_____________dollars ($_____________________) which is an amount not less than the total of 3 months Medicaid

payments to the facility computed on the basis of the preceding 12 month average Medicaid payments to the facility.

2. This bond and obligation under the bond shall remain in full force and effect from its effective date of

___________________________ until its expiration date of _____________________________ unless the bond is

terminated and canceled in the manner provided or as otherwise provided by law.

3. The Agency action through the Secretary, reserves the right, at any time to terminate this bond, except as to any liability

already incurred or accrued, by written notice of such termination to the surety delivered or mailed by certified or

registered mail. On expiration of the period designated in such notice, which period shall not be less than sixty (60) days

from the time the notice was mailed, this bond shall terminate and be of no further force or effect except as to any liability

incurred or accrued prior to termination.

4. In the event principal and surety, or either of them, cancels this bond, written notice of the filing of such cancellation

shall be immediately given by both principal and surety, to the following address. Surety reserves the right to terminate

this bond at any time, such termination to be effected by surety’s giving sixty (60) days written notice, including reason,

by certified or registered mail to:

The principal and State of Florida, Agency for Health Care Administration, Health Facility Regulation, Long

Term Care Section (MS33), 2727 Mahan Drive, Tallahassee, FL 32308.

AHCA Form 3110-6009 - July, 2001

Leased Nursing Home Surety Bond Form - Agency For Health Care Administration

Related Articles

Related forms

Related Categories