Form 3212, Birthing Center License Application

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Documents

Effective Date: 2/2023

Instructions

Updated: 2/2023

Purpose

Form 3212 is used to apply for an initial or change of ownership license for a birthing center. 

Procedure

When to Prepare

An applicant must submit the application form, license fee and other documents and complete all actions as required by Texas Administrative Code Title 25 (25 TAC), Section 137.11 Application Procedures and Issuance of Licenses. Information regarding licensure for birthing centers is located on the HHSC Birthing Centers webpage.

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

Texas Health and Human Services Commission 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 3212 no earlier than 90 calendar days before the projected opening date of the facility.
    • A license fee of $2,000.00. 
      • Make checks payable to the Texas Health and Human Services Commission.
      • License fees are not refundable.
  • 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 the administrator listed on the application to attend. For more information or to schedule the pre-licensure conference, contact the designated Regional Office.

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 3212 at least 60 calendar days before the date of the change of ownership.
    • A license fee of $2,000.00. 
      • Make checks payable to the Texas Health and Human Services Commission.
      • License fees are not refundable.
    • A notarized affidavit signed by the previous owner acknowledging agreement with the change of ownership.
    • If applicant is a corporation, a copy of the articles of incorporation.
    • If applicant is a business entity other than a corporation, a copy of the sales agreement.
  • 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 the administrator listed on the application to attend. For more information or to schedule the pre-licensure conference, contact the designated Regional Office.

Important Items to Note

  • The Doing Business As (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 legal entity directly responsible for the day-to-day operation of the facility. The legal name and Employer Identification number (EIN) on the application should be an exact match with the IRS letter, Secretary of State documentation and ownership structure.
  • The 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 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

Texas Health and Human Services Commission
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