Barbara ford-coates

SCOTT RANDOLPH, ORANGE COUNTY TAX COLLECTOR
Local Business Tax Department
201 South Rosalind Avenue
Second Floor
PAIN MANAGEMENT CLINIC AFFIDAVIT
(FOR USE AS OF JANUARY 18, 2013)
PMC state registration number, if applicable: _____________________________________________

In accordance with Section 38-1, Orange County Code, a Pain Management Clinic is defined to mean any publicly
or privately owned facility that meets the following criteria and is required to register pursuant to section 458.3265
or 459.0137, Florida Statutes. Definition per section 458.3265 or 459.0137, Florida Statutes, a Pain Management
Clinic is any publicly or privately owned facility:
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That advertises in any medium for any type of pain-management services; or Where in any month a majority of patients are prescribed opioids, benzodiazepines, barbiturates, or carisoprodol for the treatment of chronic nonmalignant pain. Exceptions: A business is not a pain management clinic if it has at least one of the following characteristics: That clinic is licensed as a facility pursuant to chapter 395; The majority of the physicians who provide services in the clinic primarily provide surgical services; The clinic is owned by a publicly held corporation whose shares are traded on a national exchange or on the over-the-counter market and whose total assets at the end of the corporation’s most recent fiscal quarter exceeded $50 million; d. The clinic is affiliated with an accredited medical school at which training is provided for medical students, The clinic does not prescribe controlled substances for the treatment of pain; The clinic is owned by a corporate entity exempt from federal taxation under 26 U.S.C. s. 501(c)(3); The clinic is wholly owned and operated by one or more board-certified anesthesiologists, physiatrists, or The clinic is wholly owned and operated by one or more board-certified medical specialists who have also completed fellowships in pain medicine approved by the Accreditation Council for Graduate Medical Education, or who are also board-certified in pain medicine by a board approved by the American Board of Medical Specialties and perform interventional pain procedures of the type routinely billed using surgical codes. DCrosby\issues by topic\pain mgmt\2012 ord\Orange Co aff eff 1-18 -13
Pain Management Clinic Affidavit
Page 2
In accordance with Section 2-467, Orange County Code, any application for a business tax receipt in specified
categories must be accompanied by an executed affidavit certifying registration with the State of Florida, if
applicable, or certifying that the business activity does not meet the definition of pain management clinic or does
not require registration as a pain management clinic prior to the business tax receipt application being forwarded to
the County Zoning Division for processing.
1. Is your facility a Pain Management Clinic, as this term is defined in Florida Statute?


2. Is this Pain Management Clinic registered with the State of Florida?

I hereby certify that information and answers provided in this application is true and correct based on my knowledge and belief. In accordance with s. 837.06, Florida Statutes, I understand and acknowledge that whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his or her official duty shall be guilty of a misdemeanor in the second degree, punishable as provided in s. 775.082 or s. 775.083, Florida Statutes. Date:__________________, 20__ STATE OF FLORIDA : COUNTY OF____________ : I certify that the foregoing instrument was acknowledged before me this _____ day of ____________, 20___ by ________________________. He/she is personally known to me or has produced _________________________ as identification and did/did not take an oath. Witness my hand and official seal in the county and state stated above on the _____ day of _____________, in the year __________. _____________________________ DCrosby\issues by topic\pain mgmt\2012 ord\Orange Co aff eff 1-18 -13

Source: http://www.octaxcol.com/Data/Sites/1/pdf/Pain%20Mgmt%20Clinic%20Affidavit.pdf