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Effective Date: 
3/2020

Documents

 

Instructions

Updated: 01/2020

 

Purpose

Form 3210 is used to apply for an initial, relocation or change of ownership license for an ambulatory surgical center. 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 135, Ambulatory Surgical Center Licensing Rules, §135.20 Initial Application and Issuance of 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/ambulatory-surgical-centers.

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

Initial Application

Change of Ownership (CHOW) Application

  • A completed Form 3210 must be submitted at least 30 calendar days before the date of the change of ownership.
  • A license fee of $5,200.00 must be submitted with the application. Make checks payable to the Texas Health and Human Services Commission. License fees are not refundable.
  • If applicable, submit a letter or certificate of accreditation from an accrediting organization which includes dates of accreditation.
  • The administrator, medical chief of staff and/or director of nurses listed on the license application must attend a presurvey conference at the Health Facility Compliance Office designated by HHSC. To schedule the presurvey conference, contact the designated office at https://hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/provider-portal/facilities-regulation/health-facility-compliance-zones.pdf.
  • A bill of sale or other legal document that shows both parties’ agreement to the sale.

Relocation

  • A completed Form 3210 must be submitted approximately 90 calendar days prior to the projected opening date of the facility
  • A license fee of $5,200.00 must be submitted with the application. Make checks payable to the Texas Health and Human Services Commission. License fees are not refundable.
  • If applicable, submit a letter or certificate of accreditation from an accrediting organization which includes dates of accreditation.
  • Approval for occupancy must be obtained from the Architectural Review Unit at https://hhs.texas.gov/doing-business-hhs/provider-portals/health-care-facilities-regulation/architectural-review.

Important Items to Note

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

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 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