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Effective Date: 
1/2020

Documents

Instructions

Updated: 01/2020

Purpose

Form 3200 is used to apply for an initial, change of ownership, or relocation license for an abortion facility. Contact Health Facility Licensing at 512-834-6648 with any questions.

Procedure

When to Prepare

The application, fees, and other documents must be submitted, as required by 25 Texas Administrative Code, Chapter 139, Abortion Facility Reporting and Licensing Rules, §139.23 Application Procedures and Issuance of Licenses. Information regarding licensure for health facilities, including contact information for the Health Facility Compliance Office for each location is located on the Texas Health and Human Services website at https://hhs.texas.gov/doing-business-hhs/provider-portals/health-care-facilities-regulation/abortion-facilities.

The following documents, fees and actions must be completed and approved before a license will be issued:

Initial Application

  • A completed Form 3200 must be submitted no earlier than 90 calendar days prior to the projected opening date of the facility.
  • A license fee of $5,000.00 must be submitted with the application. Make checks payable to the Texas Health and Human Services Commission. License fees are not refundable.
  • Provide the organizational structure of all staff for the facility.
  • A pre-licensing inspection must be conducted by HHSC prior to licensure.

Change of Ownership (CHOW) Application

  • A completed Form 3200 must be submitted at least 60 calendar days prior to the desired date of the change of ownership.
  • A license fee of $5,000.00 must be submitted with the application. Make checks payable to the Texas Health and Human Services Commission. License fees are not refundable.
  • Provide the organizational structure of all staff for the facility.
  • Provide evidence of the Change of Ownership.
  • A pre-licensing inspection must be conducted by HHSC prior to licensure.

Relocation

  • A completed Form 3200 must be submitted at least 60 days in advance of the relocation.
  • A license fee of $5,000.00 must be submitted with the application. Make checks payable to the Texas Health and Human Services Commission. License fees are not refundable.
  • Provide the organizational structure of all staff for the facility.
  • A pre-licensing inspection must be conducted by HHSC prior to licensure.

Example of Ownership Structure

  • Higher Level of Ownership and Employer Identification Number (EIN)
  • Legal Name and EIN Number
  • Doing Business As (DBA) or Assumed Name

Mailing Address for Applications with Fees

HHSC AR MC1470
P.O. Box 149055 
Austin, TX 78714-9055

Overnight Address for Applications with Fees

HHSC AR MC1470
1100 West 49th Street
Austin, TX 78756