Form 3209 "Chemical Dependency Treatment Facility Licensure Application Checklist for Change in Status Applicants" - Texas

What Is Form 3209?

This is a legal form that was released by the Texas Health and Human Services - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2020;
  • The latest edition provided by the Texas Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 3209 by clicking the link below or browse more documents and templates provided by the Texas Health and Human Services.

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Download Form 3209 "Chemical Dependency Treatment Facility Licensure Application Checklist for Change in Status Applicants" - Texas

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Form 3209
December 2020-E
Service Code: 529201043
Chemical Dependency Treatment Facility Licensure Application Checklist for Change in
Status Applicants
Currently licensed chemical dependency treatment facilities seeking to add a new site or make changes to a licensed facility must submit Form
3207, Chemical Dependency Treatment Facility Licensure Application, licensure fees, this application checklist (Form 3209) and supplemental
documentation. Submit the required items in a timely manner to ensure sufficient time for review and response, as necessary. Submit all items
above and payment to:
Texas Health and Human Services Commission
Health Facility Licensing, Service Code 529201043
P.O. Box 149055
Austin, Texas 78714-9055
Change in Status Applicant for New Site
Form 3207, Chemical Dependency Treatment Facility Licensure Application [25 TAC §448.403].
Fees - Licensure fees are not refundable. Fees shall be paid in full by cashier’s check or money order. Make payable to: Texas Health and
Human Services Commission [25 TAC §448.408].
IRS Letter - Internal Revenue Service letter assigning the Federal Employer Identification Number (FEIN) to the applicant applying for
licensure.
Certificate of Filing - List that shows entity’s full name under the “legal name” and attach a certificate of status from the Secretary of
State’s office to establish the applicant’s legal status. A sole proprietor should list the individual’s name under “legal name of applicant.”
Assumed Name Certificate (if applicable) - To be included on a license, an assumed name listed on an application must be accompanied
by a corresponding certificate of assumed name filed with the Secretary of State and/or applicable county clerk’s office, as required by
applicable law.
Facility’s Operational Plan [25 TAC §448.502(a) (1-4)].
Proof of Liability Insurance - Legal name and site address must be listed [25 TAC §448.403].
ADA Checklist - Complete the 89-page Americans with Disabilities Act checklist for each building and/or suite to be licensed [25 TAC
§448.505].
Certificate of Occupancy - Copy of Certificate of Occupancy from the local authority that reflects the current use by the occupant or
documentation that the locality does not issue occupancy certificates [25 TAC §448.505].
Lease Agreement/Deed - Copy of the lease agreement or deed to the site address that reflects the legal name of the applicant as tenant
or owner.
Floor Plan - Copy of a floor plan that clearly identifies what the facility site address will entail at each room.
Co-Location List (if applicable) - Submit a listing of all non-substance use disorder treatment services and/or programs provided at the site
address listed on Form 3207. Guidance regarding co-location can be reviewed at
https://hhs.texas.gov/doing-business-hhs/provider-
portals/health-care-facilities-regulation/substance-abuse-treatment-facilities.
Detoxification Applicants Only – Additional Documentation
Name and license number of medical director [25 TAC §448.902].
Residential Applicants Only – Additional Documentation
Inspection by the local certified fire inspector or the State Fire Marshal [25 TAC §448.1202].
Inspection of the alarm system by the fire marshal or an inspector authorized to install and inspect such systems [25 TAC §448.1202].
Kitchen health inspection by the local health authority or the Texas Department of State Health Services [25 TAC §448.1202].
Gas pipe pressure test performed by the local gas company or a licensed plumber [25 TAC §448.1202].
Inspection and maintenance of fire extinguishers by personnel licensed or certified to perform said duties [25 TAC §448.1202].
Fire alarm installation certificate which reflects installation by agents registered with the State Fire Marshal [25 TAC §448.1206].
Floor plan indicating total square footage of each room and the number and type of bed(s) (bunk or single) per room in which clients will
sleep [25 TAC §448.1205].
Form 3209
December 2020-E
Service Code: 529201043
Chemical Dependency Treatment Facility Licensure Application Checklist for Change in
Status Applicants
Currently licensed chemical dependency treatment facilities seeking to add a new site or make changes to a licensed facility must submit Form
3207, Chemical Dependency Treatment Facility Licensure Application, licensure fees, this application checklist (Form 3209) and supplemental
documentation. Submit the required items in a timely manner to ensure sufficient time for review and response, as necessary. Submit all items
above and payment to:
Texas Health and Human Services Commission
Health Facility Licensing, Service Code 529201043
P.O. Box 149055
Austin, Texas 78714-9055
Change in Status Applicant for New Site
Form 3207, Chemical Dependency Treatment Facility Licensure Application [25 TAC §448.403].
Fees - Licensure fees are not refundable. Fees shall be paid in full by cashier’s check or money order. Make payable to: Texas Health and
Human Services Commission [25 TAC §448.408].
IRS Letter - Internal Revenue Service letter assigning the Federal Employer Identification Number (FEIN) to the applicant applying for
licensure.
Certificate of Filing - List that shows entity’s full name under the “legal name” and attach a certificate of status from the Secretary of
State’s office to establish the applicant’s legal status. A sole proprietor should list the individual’s name under “legal name of applicant.”
Assumed Name Certificate (if applicable) - To be included on a license, an assumed name listed on an application must be accompanied
by a corresponding certificate of assumed name filed with the Secretary of State and/or applicable county clerk’s office, as required by
applicable law.
Facility’s Operational Plan [25 TAC §448.502(a) (1-4)].
Proof of Liability Insurance - Legal name and site address must be listed [25 TAC §448.403].
ADA Checklist - Complete the 89-page Americans with Disabilities Act checklist for each building and/or suite to be licensed [25 TAC
§448.505].
Certificate of Occupancy - Copy of Certificate of Occupancy from the local authority that reflects the current use by the occupant or
documentation that the locality does not issue occupancy certificates [25 TAC §448.505].
Lease Agreement/Deed - Copy of the lease agreement or deed to the site address that reflects the legal name of the applicant as tenant
or owner.
Floor Plan - Copy of a floor plan that clearly identifies what the facility site address will entail at each room.
Co-Location List (if applicable) - Submit a listing of all non-substance use disorder treatment services and/or programs provided at the site
address listed on Form 3207. Guidance regarding co-location can be reviewed at
https://hhs.texas.gov/doing-business-hhs/provider-
portals/health-care-facilities-regulation/substance-abuse-treatment-facilities.
Detoxification Applicants Only – Additional Documentation
Name and license number of medical director [25 TAC §448.902].
Residential Applicants Only – Additional Documentation
Inspection by the local certified fire inspector or the State Fire Marshal [25 TAC §448.1202].
Inspection of the alarm system by the fire marshal or an inspector authorized to install and inspect such systems [25 TAC §448.1202].
Kitchen health inspection by the local health authority or the Texas Department of State Health Services [25 TAC §448.1202].
Gas pipe pressure test performed by the local gas company or a licensed plumber [25 TAC §448.1202].
Inspection and maintenance of fire extinguishers by personnel licensed or certified to perform said duties [25 TAC §448.1202].
Fire alarm installation certificate which reflects installation by agents registered with the State Fire Marshal [25 TAC §448.1206].
Floor plan indicating total square footage of each room and the number and type of bed(s) (bunk or single) per room in which clients will
sleep [25 TAC §448.1205].
Form 3209
Page 2 / 12-2020-E
Change in Status Applicant for Treatment Service Changes
Form 3207, Chemical Dependency Treatment Facility Licensure Application [25 TAC §448.403].
Fees - Licensure fees are not refundable. Fees shall be paid in full by cashier’s check or money order. Make payable to: Texas Health and
Human Services Commission [25 TAC §448.408].
Facility’s Operational Plan [25 TAC §448.502(a) (1-4)].
Co-Location List (if applicable) - Submit a listing of all non-substance use disorder treatment services and/or programs provided at the site
address listed on Form 3207. Guidance regarding co-location can be reviewed at
https://hhs.texas.gov/doing-business-hhs/provider-
portals/health-care-facilities-regulation/substance-abuse-treatment-facilities.
If the facility fails to provide the information HHSC requires to process the change in status application within six months from the date of
application, the application may be denied. The facility shall not reapply for six months from the date of denial [25 TAC §448.405 (b)].
An application under Health and Safety Code, Chapter 464, and 25 TAC Chapter 448 is for licensure as a chemical dependency treatment
facility only, and issuance of a license under those provisions does not satisfy any other applicable requirement for licensure or other form of
authorization.
Acknowledgment and Signature
I acknowledge that all required items indicated on this checklist and licensure fees are submitted as the application packet for licensure as a
substance abuse treatment facility for:
By signing below, I attest that I am authorized to submit this application and to act on behalf of the above named applicant. I have thoroughly
reviewed the Standard of Care Rules at 25 TAC Chapter 448, and I accept responsibility for full knowledge and compliance by our facility and
personnel with all applicable laws, including the Standard of Care Rules in 25 TAC Chapter 448, including revisions.
CEO/Facility Contact Printed Name
CEO/Facility Contact Signature
Date
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