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Effective Date: 
2/2020

Documents

 

Instructions

Updated: 02/2020

 

Purpose

Form 3216 is used to apply for an initial, relocation or change of ownership license for a psychiatric hospital. 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 26 Texas Administrative Code, Chapter 510, Private Psychiatric Hospitals and Crisis Stabilization Units Licensing Rules, §510.22 Application and Issuance of Initial License. Information regarding licensure for health care facilities, including contact information for the Health Facility Compliance Zone 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/hospitals-private-psychiatric-hospitals-crisis-stabilization-units.

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

Initial Application

  • A completed Form 3216 shall be submitted approximately 90 calendar days prior to the projected opening date of the hospital.
  • A license fee of $200.00 per bed shall be submitted with the application. Make checks payable to the Texas Health and Human Services Commission. License fees are not refundable.
  • A copy of the hospital’s Patient Transfer Policy that is in accordance with §510.43 Patient Transfer Policy and signed by the chairman and secretary of the Governing Body shall be submitted.
  • A copy of the hospital’s Memorandum of Transfer form that is in accordance with §510.43(d)(10)(B) shall be submitted.
  • A completed Fire Safety Survey Report form shall be submitted. Annual fire safety inspections are required for continued licensure status. Include 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 administrator or a licensed professional who is listed on the license application shall attend a presurvey conference at the Health Facility Compliance Zone 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.

Relocation

  • A completed Form 3216 shall be submitted approximately 90 calendar days prior to the projected opening date of the hospital.
  • A license fee of $200.00 per bed shall be submitted with the application. Make checks payable to the Texas Health and Human Services Commission. License fees are not refundable.
  • A copy of the hospital’s Patient Transfer Policy that is in accordance with §510.43 Patient Transfer Policy and signed by the chairman and secretary of the Governing Body shall be submitted.
  • A copy of the hospital’s Memorandum of Transfer form that is in accordance with §510.43(d)(10)(B) shall be submitted. Note: Patient Transfer Agreements for private psychiatric hospitals are not required to be submitted to HHSC for approval.
  • A copy of the letter or certificate of accreditation from an authorized accrediting agency which includes dates of accreditation shall be submitted.
  • A completed Fire Safety Survey Report form shall be submitted. Annual fire safety inspections are required for continued licensure status. Include 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.

Change of Ownership (CHOW) Application

  • A completed Form 3216 shall be submitted prior to the date of the CHOW or not later than 10 calendar days following the date of the CHOW.
  • A license fee of $200.00 per bed shall be submitted with the application. Make checks payable to the Texas Health and Human Services Commission. License fees are not refundable.
  • A copy of the hospital’s Patient Transfer Policy that is in accordance with §510.43 Patient Transfer Policy and signed by the chairman and secretary of the Governing Body shall be submitted.
  • A copy of the hospital’s Memorandum of Transfer form that is in accordance with §510.43(d)(10)(B) shall be submitted. Note: Patient Transfer Agreements for private psychiatric hospitals are not required to be submitted to HHSC for approval.
  • A copy of the letter or certificate of accreditation from an authorized accrediting agency which includes dates of accreditation shall be submitted.
  • Copies of two completed Fire Safety Survey Report forms shall be submitted. Annual fire safety inspections are required for continued licensure status. Include a copy of a fire inspection report conducted within the last 12 months and a second report conducted within the last 13 to 24 months indicating approval by the local fire authority.
  • The administrator or a licensed professional who is listed on the license application shall attend a presurvey conference at the Health Facility Compliance Zone 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 the effective date of the CHOW and both parties’ agreement to the sale.

Important Items to Note

  • The Doing Business As (DBA) or assumed name of the hospital 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 hospital is the name that will appear on the license certificate and should match advertisements and signage of the hospital.
  • The legal name is the name of the direct owner legally responsible for the day-to-day operation of the hospital, whether by lease or ownership. The legal name and Employer Identification number (EIN) on the application should be an exact match with the IRS letter.
  • The organizational chart showing 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 (direct owner), 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 Zone 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. For information on obtaining provider certification, contact Zone Office staff.

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 West 49th Street
Austin, TX 78756