Form 3226, Freestanding Emergency Medical Care Facility License Application

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Documents

Effective Date: 2/2024

Instructions

Updated: 2/2024

Purpose

Form 3226 is used to apply for an initial, change of ownership, or relocation license for a freestanding emergency medical care facility. 

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 Title 26 (26 TAC) Section 509.24, Application and Issuance of Initial License. Information about licensure for freestanding emergency medical care facilities is located on the HHSC Freestanding Emergency Medical Care Facilities webpage.

Visit the Health Care Facilities Regulation Contact Us webpage for Health Care Regulation contact information.

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 before the projected opening date of the facility.
    • A license fee of $14,820.00.
      • Make checks payable to the Texas Health and Human Services Commission.
      • License fees are not refundable.
    • A copy of the following patient transfer documents for the facility:
    • 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 opening date. 
      • Annual fire safety inspections are required for continued licensure.
  • Obtain approval for occupancy from the Architectural Review Unit.
  • Attend a pre-licensure conference (previously called pre-survey conference) conducted by the HFC unit. HFC holds pre-licensure conferences once a month and requires one or more of the following people to attend: the administrator, medical chief of staff or director of nurses listed on the application. Contact the designated HFC regional office (PDF) for more information or to schedule the pre-licensure conference.
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 $14,820.00.
      • Make checks payable to the Texas Health and Human Services Commission.
      • License fees are not refundable.
    • A copy of the following patient transfer documents for the facility:
    • A copy of the letter or certificate of accreditation from an authorized accrediting agency which includes effective dates of accreditation (if applicable).
    • 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 opening date.
      • Annual fire safety inspections are required for continued licensure.
  • Obtain approval for occupancy from the Architectural Review Unit.
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 $14,820.00.
      • Make checks payable to the Texas Health and Human Services Commission.
      • License fees are not refundable.
    •  A copy of the following patient transfer documents for the facility:
    • A copy of the letter or certificate of accreditation from an authorized accrediting agency which includes effective dates of accreditation (if applicable).
    • 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 before the opening date.
      • Annual fire safety inspections are required for continued licensure.
    • A Bill of Sale or other legal document that includes the effective date of the CHOW and both parties’ signed agreement to the sale.
  • Attend a pre-licensure conference (previously called pre-survey conference) conducted by the HFC unit or request a waiver. HFC holds pre-licensure conferences once a month and requires one or more of the following people to attend: the administrator, medical chief of staff or director of nurses listed on the application. Contact the designated HFC regional office (PDF) for more information or to schedule the pre-licensure conference.

Important Items to Note:

  • The Doing Business As (DBA) or assumed name listed on the application must match the DBA or assumed name listed on applications filed with the Texas State Board of Pharmacy and the Drug Enforcement Agency.
  • The DBA 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 DBA 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 Mail Code 1470
4601 W. Guadalupe Street
Austin, TX 78751