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Effective Date: 
1/2020

Documents

Instructions

Updated: 01/2020

Purpose

Form 3212 is used to apply for an initial or change of ownership license for a birthing 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 137, Birthing Center Licensing Rules, §137.11 Application Procedures and Issuance of Licenses. 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/birthing-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 3212 must be submitted at least 60 calendar days before the date of the change of ownership.
  • A license fee of $2,000.00 must be submitted with the application. Make checks payable to the Texas Health and Human Services Commission. License fees are not refundable.
  • Attach a bill of sale or other legal document that shows both parties’ agreement to the sale to the application.
  • The administrator listed on the 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

Important Items to Note

  • The Doing Business As (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

Mailing Address for Applications with Fees

Texas Health and Human Services Commission
HHSC AR MC1470
P.O. Box 149055
Austin, TX 78714-9055

Overnight Address for Applications with Fees

Texas Health and Human Services Commission
HHSC AR MC1470
1100 West 49th Street
Austin, TX 78756