Form 3210, Ambulatory Surgical Center License Application

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Documents

Effective Date: 1/2023

Instructions

Updated: 1/2023

Purpose

Form 3210 is used to apply for an initial, relocation or change of ownership license for an ambulatory surgical 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 135.20 Initial Application and Issuance of License. Information regarding licensure for ambulatory surgical centers is located on the HHSC Ambulatory Surgical 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 3210 approximately 90 calendar days before the projected opening date of the facility.
    • A license fee of $5,200.00. 
      • Make checks payable to the Texas Health and Human Services Commission. 
      • License fees are not refundable.
  • Obtain approval for occupancy from the Architectural Review Unit.
  • 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 or a licensed professional who is listed on the application to attend. For more information or to schedule the pre-licensure conference, 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 3210 approximately 30 calendar days before the projected opening date of the facility.
    • A license fee of $5,200.00.
      • Make checks payable to the Texas Health and Human Services Commission.
      • License fees are not refundable.
    • If applicable, a letter or certificate of accreditation from an accrediting organization which includes dates of accreditation.
  • Obtain approval for occupancy from the Architectural Review Unit.

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 3210 at least 30 calendar days before the date of the change of ownership.
    • A license fee of $5,200.00. 
      • Make checks payable to the Texas Health and Human Services Commission. 
      • License fees are not refundable.
    • A bill of sale or other legal document that shows both parties’ agreement to the sale.
    • If applicable, a letter or certificate of accreditation from an accrediting organization which includes dates of accreditation.
  • 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 or a licensed professional who is 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 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

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 an HHSC responsibility. For information on obtaining provider certification, contact the Regional Office for your location.

Visit the HHSC Clinical Laboratory Improvement Amendment (CLIA) webpage for information on CLIA.

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