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Effective Date: 
5/2021

Documents

Instructions

Updated: 9/2021

Purpose

Form 3226 is used to apply for an initial, change of ownership or relocation license for a freestanding emergency medical care facility. Contact Health Facility Licensing at 512-834-6648 with any questions.

Information regarding licensure for health care facilities, including contact information for the Health Facility Compliance (HFC) regional offices, is located on the Texas Health and Human Services (HHS) website at https://hhs.texas.gov/doing-business-hhs/provider-portals/health-care-facilities-regulation/freestanding-emergency-medical-care-facilities.  

Procedure

When to Prepare

An applicant must submit the application form, license fee and other applicable documents and complete all actions as required by Texas Administrative Code (TAC), Title 25 Chapter 131, Freestanding Emergency Medical Care Facilities Licensing Rules, §131.25, Application and Issuance of Initial License.

Texas Health and Human Services Commission (HHSC) must approve all required application materials received before HHSC will issue a license to the applicant.

Initial Application

An applicant for an initial license must complete the following requirements.

  • Submit the following to HHSC:
    • A completed Form 3226 at least 90 calendar days prior to the projected opening date of the facility;
    • A license fee of $7,410.00 as required by 25 TAC §131.31(a), for a two-year license term total of $14,820.00 in accordance with Health and Safety Code (HSC) §254.053;
    • A copy of the following patient transfer documents for the facility:
      • Patient Transfer Policy, signed by the facility's chairman and secretary of the governing body, that meets the requirements of 25 TAC §131.66, Patient Transfer;
      • Memorandum of Transfer form that meets the requirements of 25 TAC §131.66(b)(9); and
      • Patient Transfer Agreement with a general hospital that meets the requirements of 25 TAC §131.67, Patient Transfer Agreements; and
    • A completed fire safety survey indicating approval by the local fire authority in whose jurisdiction the facility is based that is dated no earlier than one year prior to the application date, as required by 25 TAC §131.25(d)(15). 
  • Obtain approval for occupancy from the Architectural Review Unit by following the procedures at https://hhs.texas.gov/doing-business-hhs/provider-portals/health-care-facilities-regulation/architectural-review.
  • Attend a pre-licensure conference (previously called pre-survey conference) conducted by the HFC unit. Pre-licensure conferences are held once a month by HFC and require one or more of the following individuals to attend: the administrator, medical chief of staff or director of nurses listed on the application. For more information or to schedule the pre-licensure conference, contact the designated HFC regional office at https://hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/provider-portal/facilities-regulation/health-care-regulation-contacts.pdf.

Relocation Application

A currently licensed facility applying for relocation must complete the following requirements.

  • Submit the following to HHSC: 
    • A completed Form 3226 at least 30 calendar days before relocation of the facility;
    • A license fee of $7,410.00 as required by 25 TAC §131.31(a), for a two-year license term total of $14,820.00 in accordance with HSC §254.053;
    • A copy of the following patient transfer documents for the facility:
      • Patient Transfer Policy, signed by the facility's chairman and secretary of the governing body, that meets the requirements of §131.66, Patient Transfer Policy;
      • Memorandum of Transfer form that meets the requirements of §131.66(b)(9); and
      • Patient Transfer Agreement with a general hospital that meets the requirements of §131.67, Patient Transfer Agreements; and
    • A completed fire safety survey indicating approval by the local fire authority in whose jurisdiction the facility is based that is dated no earlier than one year prior to the application date, as required by 25 TAC §131.25(d)(15).
  • Obtain approval for occupancy from the Architectural Review Unit by following the procedures at https://hhs.texas.gov/doing-business-hhs/provider-portals/health-care-facilities-regulation/architectural-review.
  • For optional accreditation: 
    • A copy of the letter or certificate of accreditation from an authorized accrediting agency which includes effective dates of accreditation.

Change of Ownership (CHOW) Application

A currently licensed facility applying for a CHOW must complete the following requirements.

  • Submit the following to HHSC:
    • A completed Form 3226 at least 30 calendar days before the date of the change of ownership; 
    • A license fee of $7,410.00 as required by 25 TAC §131.31(a), for a two-year license term total of $14,820.00 in accordance with HSC §254.053; 
    • A copy of the following patient transfer documents for the facility:
      • Patient Transfer Policy, signed by the facility's chairman and secretary of the governing body, that meets the requirements of §131.66, Patient Transfer Policy; 
      • Memorandum of Transfer form that meets the requirements of §131.66(b)(9); and
      • Patient Transfer Agreement with a general hospital meets the requirements of §131.67, Patient Transfer Agreements;
    • A completed fire safety survey indicating approval by the local fire authority in whose jurisdiction the facility is based that is dated no earlier than one year prior to the application date, as required by 25 TAC §131.25(d)(15); and
    • A Bill of Sale or other legal document reflecting the CHOW, which must include the effective date of the CHOW and both parties signed agreement to the transaction.
  • Attend a pre-licensure conference (previously called pre-survey conference) conducted by the HFC unit or request a waiver. Pre-licensure conferences are held once a month by HFC and require one or more of the following individuals to attend: the administrator, medical chief of staff or director of nurses listed on the application. For more information or to schedule the pre-licensure conference, contact the designated HFC regional office at https://hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/provider-portal/facilities-regulation/health-care-regulation-contacts.pdf.
  • For optional accreditation: 
    • A copy of the letter or certificate of accreditation from an authorized accrediting agency which includes effective dates of accreditation.
       

Important Items to Note:

  • Make checks for all license fees payable to Texas Health and Human Services Commission. License fees are not refundable.
  • Annual fire safety inspections are required for continued licensure status.
  • The D/B/A or assumed name listed on the application must match the D/B/A or assumed name listed on applications filed with the Texas State Board of Pharmacy and the Drug Enforcement Agency.
  • The D/B/A or assumed name of the facility is the name that will appear on the license certificate and should match advertisements and signage of the facility.
  • The legal name is the name of the direct owner legally responsible for the day-to-day operation of the facility, whether by lease or ownership. The legal name and Employer Identification Number (EIN) on the application should be an exact match with the IRS letter.
  • The organizational chart showing ownership structure should reflect all levels of ownership and include EIN numbers. The chart should start with the D/B/A or assumed name, continue with the legal name (direct owner) and end with any additional ownership levels. Below is an example of ownership structure: 
    • Higher Level of Ownership and EIN
    • Legal Name and EIN Number
    • DBA or Assumed Name

Mailing Address for Applications with Fees

HHSC AR Mail Code 1470 
P.O. Box 149055 
Austin, TX 78714-9055

Overnight Address for Applications with Fees

HHSC AR MC1470
4601 W. Guadalupe Street
Austin, TX 78751