Form 3200, Abortion Facility License Application

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Documents

Effective Date: 2/2023

Instructions

Updated: 2/2023

Purpose

Form 3200 is used to apply for an initial, change of ownership, or relocation license for an abortion facility. 

Procedure

When to Prepare

An applicant must submit the application form, license fees, and other documents, and complete all actions as required by Texas Administrative Code Title 25 (25 TAC) Section 139.23 Application Procedures and Issuance of Licenses. Information regarding licensure for abortion facilities is located on the HHSC Abortion Facilities webpage.

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 3200 no earlier than 90 calendar days before the projected opening date of the facility.
    • A license fee of $5,000.00 
      • Make checks or money orders payable to the Texas Health and Human Services Commission. 
      • License fees are not refundable.
    • The organizational structure of all staff for the facility.
  • A pre-licensing inspection must be conducted by HHSC before licensure. For more information, 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 3200 submitted at least 60 calendar days before the desired date of the change of ownership.
    • A license fee of $5,000.00. 
      • Make checks payable to the Texas Health and Human Services Commission. 
      • License fees are not refundable.
    • The organizational structure of all staff for the facility.
    • A Bill of Sale or other legal document that shows both parties’ agreement to the sale.
  • A pre-licensing inspection must be conducted by HHSC before licensure. For more information, contact the designated Regional Office.

Relocation

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

  • Submit the following to HHSC:
    • A completed Form 3200 submitted at least 60 days in advance of the relocation.
    • A license fee of $5,000.00. 
      • Make checks payable to the Texas Health and Human Services Commission. 
      • License fees are not refundable.
    • The organizational structure of all staff for the facility.
    • A pre-licensing inspection must be conducted by HHSC before licensure. For more information, contact the designated Regional Office.

Example of Ownership Structure

The organizational chart showing ownership structure should reflect all levels of ownership and include EIN numbers. The chart should start with the Doing Business As (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 Employer Identification Number (EIN)
  • Legal Name and EIN Number
  • Doing Business As (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