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Effective Date: 
1/2020

Documents

 

Instructions

Updated: 1/2020

Purpose

Form 3204 is used to apply for an initial, relocation or change of ownership license for an end stage renal disease facility. Contact Health Facility Licensing at 512-834-6648 with any questions.

Procedure

When to Prepare
The application, fees and other documents shall be submitted, as required by 25 Texas Administrative Code, Chapter 117, End Stage Renal Disease Facility Licensing Rules, §117.12 Application and Issuance of Initial License. Information regarding licensure for health care 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/end-stage-renal-disease-facilities.

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

Initial Application

Relocation

  • A completed Form 3204 submitted no earlier than 90 calendar days prior to the projected opening date of the facility.
  • A license fee ranging from $3,500.00 to $6,700.00, based on the total number of stations, shall be submitted. Make checks payable to the Texas Health and Human Services Commission. License fees are not refundable.
  • A written plan for the orderly transfer of care of patients and clinical records, in the event the facility is unable to maintain services under the license.
  • A copy of a fire inspection report conducted within the last 12 months, indicating approval by the local fire authority.
  • Approval for occupancy shall be obtained from the Architectural Review Unit at https://hhs.texas.gov/doing-business-hhs/provider-portals/health-care-facilities-regulation/architectural-review.
  • The facility shall submit a complete chemical analysis of the product water and reports to verify that bacteriological and endotoxin levels of product water and dialysate are compliant with §117.32 (relating to Water Treatment, Dialysate Concentrates and Reuse). Reports shall be submitted to the designated Health Facility Compliance Office for approval. Contact the designated office with any questions.
  • Medicare certified facilities shall complete the Life Safety Code Attestation available at https://hhs.texas.gov/doing-business-hhs/provider-portals/health-care-facilities-regulation/end-stage-renal-disease-facilities.

Change of Ownership (CHOW) Application

Important Items to Note

  • The Doing Business As (DBA) or assumed name of the facility is the name that will appear on the license and should match advertisements and signage 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

Additional Information

Medicare certification information may be obtained from the Health Facility Compliance Office at https://hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/provider-portal/facilities-regulation/health-facility-compliance-zones.pdf. 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 one of HHSC’s responsibilities.

Clinical Laboratory Improvement Amendment (CLIA) information is located at https://hhs.texas.gov/doing-business-hhs/provider-portals/health-care-facilities-regulation/laboratories-clinical-laboratory-improvement-amendments.

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
1100 W. 49th St.
Austin, TX 78756