Form 3240, Limited Services Rural Hospital (LSRH) License Application

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Documents

Effective Date: 10/2023

Instructions

Updated: 10/2023

Purpose

Form 3240 is used to apply for an initial, change of ownership or relocation license for a limited services rural hospital. 

Procedure

When to Prepare

An applicant must submit the application form, license fee and other applicable documents, and complete all actions as required by 26 Texas Administrative Code (TAC) Section 511.12 Application and Issuance of Initial License. 

For Health Care Regulation contact information, visit the Health Care Facilities Regulation Contact Us webpage.

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 3240 within 60 calendar days before the projected opening date of the LSRH.
    • A license fee of $350.
      • Make checks payable to the Texas Health and Human Services Commission.
      • License fees are not refundable.
    • Patient transfer documents that include:
      • A copy of the LSRH patient transfer policy, signed by the chairman and secretary of the governing body per 26 TAC 511.12(a)(2) and 26 TAC 511.65.
      • A copy of the LSRH Memorandum of Transfer per 26 TAC 511.12(a)(3) and 26 TAC 511.65.
      • A copy of the LSRH patient transfer agreement per 26 TAC 511.12(a)(4) and 26 TAC 511.66.
    • A copy of a fire inspection approved by an individual certified by the Texas Commission on Fire Protection that is dated no earlier than one year before the LSRH application submission date per 26 TAC 511.12(5).
      • Annual fire safety inspections are required for continued licensure.
  • If applicable, obtain approval for occupancy from the HHSC Architectural Review Unit per 26 TAC Section 511.12(b).
  • Attend a pre-licensure conference (previously called pre-survey conference) conducted by the Health Facility Compliance unit. HFC holds pre-licensure conferences once a month and requires one or more of the following individuals to attend: the LSRH CEO, administrator, or another individual listed on the application. For more information or to schedule the pre-licensure conference, contact the designated Regional Compliance Office (PDF).

Relocation Application

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

  • Submit the following to HHSC:
    • A completed Form 3240 within 60 calendar days before the projected opening date of the LSRH.
    • A license fee of $350.
      • Make checks payable to the Texas Health and Human Services Commission.
      • License fees are not refundable.
    • Patient transfer documents that include:
      • A copy of the LSRH patient transfer policy, signed by the chairman and secretary of the governing body per 26 TAC 511.12(a)(2) and 26 TAC 511.65.
      • A copy of the LSRH Memorandum of Transfer per 26 TAC 511.12(a)(3) and 26 TAC 511.65.
      • A copy of the LSRH patient transfer agreement per 26 TAC 511.12(a)(4) and 26 TAC 511.66.
    • A copy of a fire inspection approved by an individual certified by the Texas Commission on Fire Protection that is dated no earlier than one year before the LSRH application submission date per 26 TAC 511.12(5).
      • Annual fire safety inspections are required for continued licensure.
  • Obtain approval for occupancy from the HHSC 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 3240 within 60 calendar days before the projected opening date of the LSRH.
    • A license fee of $350.
      • Make checks payable to the Texas Health and Human Services Commission.
      • License fees are not refundable.
    • Patient transfer documents that include:
      • A copy of the LSRH patient transfer policy, signed by the chairman and secretary of the governing body per 26 TAC 511.12(a)(2) and 26 TAC 511.65.
      • A copy of the LSRH Memorandum of Transfer per 26 TAC 511.12(a)(3) and 26 TAC 511.65.
      • A copy of the LSRH patient transfer agreement per 26 TAC 511.12(a)(4) and 26 TAC 511.66.
    • A copy of a fire inspection approved by an individual certified by the Texas Commission on Fire Protection that is dated no earlier than one year before the LSRH application submission date per 26 TAC 511.12(5).
      • 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 transaction.
  • Attend a pre-licensure conference (previously called pre-survey conference) conducted by the Health Facility Compliance unit. HFC holds pre-licensure conferences once a month and requires one or more of the following individuals to attend: the LSRH CEO, administrator, or another individual listed on the application. For more information, to schedule the pre-licensure conference or request a waiver, contact the designated Regional Compliance Office (PDF).

Important Items to Note

  • The Doing Business As (DBA) or assumed name of the LSRH 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

Additional Information

The Social Security Act directs the Secretary of the Department of Health and Human Services to use the help of state health agencies or other appropriate agencies to determine if health care entities meet federal standards. This task is an HHSC responsibility. For information on obtaining provider certification, contact the Regional Compliance Office for your location (PDF).

Visit the HHSC Clinical Laboratory Improvement Amendment (CLIA) webpage for information on CLIA.

Mailing Address for Applications with Fees:

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

Overnight Address for Applications with Fees:

HHSC AR Mail Code 1470
4601 W. Guadalupe Street
Austin, TX 78751