Complete this form to request an increase to a facility's licensed capacity, which may be in conjunction with a renewal.
Retain a copy of the application and all supporting documents submitted to HHSC for your records.
Mail fees to:
Health and Human Services Commission
Accounts Receivable (Mail Code 1470)
P.O. Box 149055
Austin, TX 78714-9055
Mail applications to:
Health and Human Services Commission
Long Term Care Regulatory Services (Mail Code E-342)
701 West 51st Street
Austin, TX 78751
Include the appropriate fee for application and mail to the address above. (Refer to the fee schedule on Item 3 of the application for the specific fee amount based on the type of application checked in Item 2.)
Complete all parts of this application.
Item 1. Facility Information
Facility Name — Enter the name of the facility. Do not abbreviate.
Facility Identification No. — Enter the facility identification number issued by the state of Texas. (Leave blank if not yet issued.)
Facility Area Code and Telephone No. — Enter the area code and telephone number at the facility location.
Physical Address - Street, City, State, ZIP Code — Enter the address of the facility, including street, city, state and ZIP Code where the facility is physically located.
County — Enter the county where the facility is located.
Facility Mailing Address (if different from Physical Address) — Self Explanatory.
Item 2. Type of Facility — Select the type of facility. Check one box per form.
Item 3. Requested Capacity Increase and Amount of Fee — Enter the current capacity for the facility, the requested number of beds and the amount of the fee based on the fee schedule.
Nursing Facility – $15 per bed
ICF/IID Facility – $5 per bed
Assisted Living Facility – $10 per bed
Day Activity and Health Services – No fee
Prescribed Pediatric Extended Care Center – $875
Item 4. Nursing Facility Administrator of Facility Serving Persons with an Intellectual Disability/Related Conditions (ICF/IID facilities only) — Enter the name, Social Security number and license number of the current administrator on file. If you are reporting a change of administrator only, submit Form 3722-N, Application for Change – Nursing Facility Administrator or Administrator for Intermediate Care Facilities Serving Individuals with an Intellectual Disability or Related Conditions.
Item 5. Fire Authority must sign below or provide separate written approval —The Fire Marshal signs and dates the form. Approval of the local fire authority is required for capacity increase license applications. The fire authority may sign the application or you may submit a signed and dated written approval in any format that identifies the facility by name and/or address. Do not delay submitting the application because you are awaiting fire marshal approval.
Ready for Life Safety Code (LSC) survey — Indicate Yes, No, or N/A Renewal/CHOW.
Expedited Life Safety Code (ELSC) survey — Indicate Yes, No, or N/A Renewal/CHOW. This is applicable to new construction and remodels for NF and ALF facilities only. The ELSC will be conducted within 15 days after receipt of the request, fee and all requirements are met. In addition, an ELSC fee is required for each ELSC visit. This fee covers only one ELSC visit. If the provider does not pass the first LSC visit and requests that the follow-up be expedited, the provider will be required to pay the ELSC fee again.
Item 6. Include a copy of the letter to the local health authority informing it of a change in the facilities license. — For capacity increase applications, send a letter to the local health authority stating that you are applying for, or requesting a change to, a facility's license. (Contact HHSC Open Records at 512-438-2633 for the name and address of the applicable local health authority.) Submit a copy of this letter with the return of the completed application.
Item 7. Affidavit for Application — Check the Facility Type (Nursing Facility, ICF/IID, Assisted Living Facility, Day Activity and Health Services, or Prescribed Pediatric Extended Care Center.
Signature and Date — The owner/applicant or authorized representative must sign and date to attest that the information included in this application, including all accompanying forms and related compliance history, is true and correct. The application must be notarized and include the notary's signature and seal or stamp.
If you need further assistance completing this form, call the HHSC Licensing and Certification Unit at 512-438-2630.