Effective Date: 
1/2014

Documents

Instructions

Updated: 1/2014

 

Procedure

Complete this form to apply for:

  • Initial
  • Change of Ownership (CHOW)
  • Renewal
  • Additional certified Alzheimer's capacity (no fee)

Transmittal

  • Mail Initial or CHOW application and non-refundable fee, with required documents, to the address referenced below.
  • Mail Renewal application and non-refundable fee to the address referenced below.
  • Mail requests for Additional Certified Alzheimer's Capacity to address referenced below.

Mail application to:

Texas Health and Human Services Commission
Accounts Receivable (E-411)
P.O. Box 149030
Austin, TX 78714-9030

Send overnight delivery to:

Texas Health and Human Services Commission
Accounts Receivable (E-411)
701 West 51st St.
Austin, TX 78751

Detailed Instructions

Part I — General Information

1. Facility Name — Enter the name of the facility exactly as it appears on your filed Assumed Name Certificate. Do not use abbreviations.

Alzheimer Unit Name — Enter the name assigned to the Alzheimer Unit.

2. Physical Address (Street, City, State, ZIP) — Enter the address of the facility, including city and ZIP Code where the facility is physically located.

County — Enter the county in which the facility is located.

Facility Area Code and Telephone No. — Enter the area code and telephone number at the facility location.

Facility Identification No. — Enter the facility ID number (leave blank if not yet issued).

Facility Program Type — Enter the program type (Example: Assisted Living Type B or Nursing Facility) with which the Alzheimer Unit is associated.

Facility Service Type — Enter the facility service type (Example: AL-B, SNF/NF or NF).

National Provider Identifier No. — Enter the facility's National Provider Identifier (NPI) number assigned by the Centers for Medicare and Medicaid Services (CMS) if applicable.

3. Current Certified Alzheimer's Capacity — Enter the current certified Alzheimer's capacity (number of beds).

4. Type of Application — Check all applicable boxes.

Alzheimer’s Assisted Living Facility (Initial) – Check this box to apply to be certified as an Alzheimer Unit, or to apply for a certificate due to expiration. Note: Certificates issued with an effective date of Sept. 1, 2008, will expire two years after the effective date and are not eligible for a one-year certificate.

Alzheimer’s Assisted Living Facility (CHOW) – Check this box to apply for a new certificate due to a CHOW. Note: CHOW certificates issued with an effective date of Sept. 1, 2008, will expire two years after the effective date and are not eligible for a one-year certificate.

Alzheimer’s Assisted Living Facility (Renewal) – Check this box to renew the facility's current certificate and enter fee total and check/money order number.

  • The first time the facility applies for renewal of a certificate with an effective date of Sept. 1, 2008, and whose license identification number ends in an odd number (1, 3, 5, 7 or 9), the certificate is valid for one year. (Subsequent renewal certificates thereafter are valid for two years).
  • The first time the facility applies for renewal of a certificate with an effective date of Sept. 1, 2008, and whose facility identification number ends in an even number (0, 2, 4, 6 or 8), the certificate is valid for two years.

Certified Alzheimer's Capacity Change – Check this box to apply for a change in the Alzheimer capacity.

  • Complete all parts of this application.
  • Enclose a copy of your letter notifying the local health authority of your application for an increase in capacity.
  • Enclose a letter with the application that states the facility meets the architectural requirements.
  • Submit a current fire marshal approval.

Long-Term Care Facility (NF) (Initial) – Check this box to apply

  • Complete all parts of this application.
  • Enclose a copy of your dated written notice to the local health authority that you have applied for a change in the facility's certification.
  • Enclose a fire marshal approval.

Long-Term Care Facility (NF) – CHOW – Check this box to apply for a new certificate due to a CHOW. The certificate is valid for three years for CHOWs with an effective date of Jan. 1, 2014, or after.

Long-Term Care Facility (NF) Renewal – The certificate is valid for one three years for licenses expiring Jan.1, 2014, or after.

Fee Schedule — All applications pay the rate indicated for the applicable type of licensure application.

  • Alzheimer’s Assisted Living Facility – The fee for initial, CHOW and renewal for a two-year certificate is $200.
  • Alzheimer’s Assisted Living Facility – The fee for a one-year certificate is $100.
  • Long-Term Care (NF) – The renewal, new facility and CHOW fee for a three year certificate is $300 (for licenses expiring Jan. 1, 2014, or Inital/CHOW lincenses with an effective date of Jan. 1, 2014, or after).

Part II — Local Authority Approvals

5. New and bed increase ... — New and bed increase applications must include written approval from the local fire authority.

To the best of my knowledge ... — Approval of the local fire authority is required for new and 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 address. Do not delay submitting the application because you are awaiting fire marshal approval.

6. All applications for license ... — Applications for license (except renewals) must include a copy of a letter to the health authority stating that a change in the facility's certification is occurring.
Note: For new, change of ownership and 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 certificate.

Part III — Owner/Applicant

Signature — Owner/Applicant (or Authorized Representative) — The owner/applicant or authorized representative must 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.

For assistance: If, after reading these instructions for completing the application, you determine you need further assistance, call the Applications and Issuance Unit at 512-438-2630 and ask to speak to a licensing specialist or enrollment specialist. To facilitate the licensing process, each application is assigned to a licensing specialist or enrollment specialist upon receipt. You will be informed of the specialist's name and telephone number for your facility's application. Any questions or correspondence relating to your application should be directed to this individual.

 

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