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    The Health Facility Program is within the Division for Regulatory Services.


    Renew Online

    Online Renewals and FAQs 

    External links to other sites are intended to be informational and do not have the endorsement of the Texas Department of State Health Services. These sites may not be accessible to people with disabilities.


Applications and Forms - Health Facility Program

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This page contains applications, forms and directories pertaining to facility licensure. Refer to File Viewing Information on the left-hand side menu to download viewers for PDF files, MS Word documents and Excel files.


Abortion Facilities

Abortion Facilities license application
Abortion Facility License Application

Word File  

PDF File
Abortion Complication Reporting Form Word File PDF File

HB15 Sonogram and Abortion Election Form
HB15 Medical Emergency Abortion Form

DSHS Vital Statistics Abortion report forms for physicians

Disclosure and Consent form
Texas Medical Board required form
(Refer questions to TMB at: www.tmb.state.tx.us)

Locate PDF file at:§ 22 TAC §165.6(f)
Informed Consent Certification form TAC §139.52(a)(1) - English
Affidavit of Age form PDF File  - Spanish

TAC §139.41(a)(8)(A) - English

Information on Toll-Free Telephone Number TAC §139.6(a)(2) - Spanish TAC §139.6(a)(1) - English

Notice to Medicaid Women's Health Program Providers

Section 32.0248, Human Resources Code, prohibits the payment of Medicaid Women's Health Program funds to a provider that performs elective abortions. This provision also applies to licensed abortion facilities. A provider that has performed elective abortions (through either surgical or medical methods) for any patient is ineligible to serve Medicaid Women's Health Program clients and cannot be reimbursed for those services. This prohibition has been in effect since September 1, 2005. This prohibition does not prohibit providers from delivering services to other Medicaid clients. The Health and Human Services Commission may recoup Medicaid Women's Health Program funds that it determines were paid to providers that have performed elective abortions.

For more information please call Alex Melis, Medicaid/CHIP Division, Health and Human Services Commission, at (512) 491-1451.


Ambulatory Surgical Centers

Ambulatory Surgical Centers
How to Become a Licensed Ambulatory Surgical Center Application Word File   PDF File  
Architectural Review Information and Forms
Disclosure and Consent forms for medical and surgical procedures
Incident Report form   PDF File  
ASC Annual Report form Word File   PDF File  
Directories of Ambulatory Surgical Centers. Excel File  

Alphabetical     

By County  

HB15 Sonogram and Abortion Election Form
HB15 Medical Emergency Abortion Form

   

Birthing Centers

Birthing Centers
Birthing Center License Application Word File     PDF   
Birthing Center Reporting PDF
Directories of Birthing Centers
Excel

Alphabetical

By County

Licensed Midwives Eligible to Enroll in Texas Medicaid Effective January 1, 2013

Beginning January 1, 2013, licensed midwife (LM) providers can enroll in Texas Medicaid. The online Provider Enrollment on the Portal (PEP) and the paper Texas Medicaid Provider Enrollment Application have been updated to allow for the enrollment of LMs.

Updated applications will be available on this website beginning December 17, 2012: http://www.tmhp.com/Pages/ProviderEnrollment/PE_TX_Medicaid_New.aspx.

The updated paper Texas Medicaid Provider Enrollment Application will be version XXII. A checkbox for the LM provider type and the Physician’s Letter of Agreement form, which will be required for LMs and certified nurse midwives, will also be added to this version of the paper application.  For more information or for assistance with completing the application, call the TMHP Contact Center at 1-800-925-9126.


Community Mental Health Centers and
Comprehensive Out-Patient Rehabilitation Facilities

Community Mental Health Centers and
Comprehensive Out-Patient Rehabilitation
Center for Medicare/Medicaid Services - Forms Link to downloadable forms
Center for Medicare/Medicaid Services - Overview Link to general overview page

End Stage Renal Disease Facilities

End Stage Renal Disease Facilities
How to Become a Licensed End Stage Renal Disease Facility Application Word File    PDF File   
Life Safety Code Attestation PDF File
Architectural Review Information and Forms
Incident Report including instructions   PDF File  
Application and Survey and Certification Report - CMS 3427

Directories of End Stage Renal Disease Facilities

Excel File

Alphabetical

By County


Freestanding Emergency Medical Care Facilities

 

Freestanding Emergency Medical Care Facilities
Freestanding Emergency Medical Care Facility License Application Word    PDF   
Freestanding Emergency Medical Care Facility License Renewal Application Word    PDF
Incident Report Form PDF  
Survey Audit Tool - Freestanding Emergency Rooms Word   PDF    

Class F Pharmacy License Instructions and Application Documents-
Please visit the Texas State Board of Pharmacy website at www.tsbp.state.tx.us.

Architectural Review Information and Forms
Directories of Freestanding Emergency Medical Care Facilities Excel  

Alphabetical  

By County

 


Hospitals - General and Special

Hospitals - General and Special
General or Special Hospital Application Word File   

PDF File  

General or Special Multiple Location Hospital Application Word File     PDF File  
General or Special Hospital Renewal Application Word File   PDF File 
General or Special Hospital Multiple Location Renewal Application Word File   PDF File  
Architectural Review Information and Forms
Fire Safety Survey Report form PDF File  
Hospital Database Worksheet PDF File
Hospital Closure Instructions PDF File  
Change of Ownership Instructions PDF File   
Community Wide Designated Hospitals for Sexual Assault Survivors (Excel 39KB)
Disclosure and Consent forms for medical and surgical procedures

ER Handout for Psychiatric Patients   (PDF 30KB)
ER Handout for Psychiatric Patients- Spanish  (PDF 160KB)

HB15 Sonogram and Abortion Election Form
HB15 Medical Emergency Abortion Form

Directories of General & Special Hospitals 
Hospital Beds   Excel File  

Alphabetical 

 By County  


Hospitals - Waiver Request

Hospitals - Waiver Request
Hospital Waiver Request-Provisions for the Regulatory Service Division - PDF File   
Emergency Department (ED) Hospital Waiver Process - PDF File  
Emergency Department Waiver Requests Approved - PDF File  

Hospitals - Psychiatric and Crisis Stabilization Units

Hospitals - Psychiatric and Crisis Stabilization Units
Psychiatric Hospital Application Word File   PDF File  
Psychiatric Multiple Location Hospital Application Word File                  PDF File   
Psychiatric Hospital Renewal Application Word File   PDF File  
Psychiatric Hospital Multiple Location Renewal Application Word File   PDF File  
Crisis Stabilization Unit License Application Word File   PDF File  
Crisis Stabilization Unit Renewal Application Word File   PDF File  
Architectural Review Information and Forms
Fire Safety Survey Report form PDF File  
Hospital Database Worksheet PDF File
CSU Directory PDF File  
Directories for Psychiatric Hospitals
Psychiatric Beds     Excel File  

Alphabetical   

By County     


Laboratories - CLIA

Laboratories - CLIA
Application for CLIA Certification
Overview of CLIA- CMS Link
Fee Schedule Information - CMS Link
CLIA Waived Testing FAQ- CDC Link

Health Facility Compliance Group staff is responsible for surveying laboratories for CMS.
For more information on the certification process, contact the appropriate zone office.
See the Zone Address List to find your appropriate zone office.


Narcotic Treatment Clinics

Narcotic Treatment Clinics

New/ATT/Renewal Application & Status Report - Narcotic Treatment Program  
Hospital Narcotic Drug Detoxification
Medication Unit

Word File    PDF File   
Narcotic Treatment Program List of Clinics By Clinic Name
PDF File

 


Out-Patient Physical Therapy | Speech Pathology Services |
Portable X-Ray Services | Rural Health Clinics

Out-Patient Physical Therapy | Speech Pathology Services |
Portable X-Ray Services | Rural Health Clinics
Center for Medicare & Medicaid Services - Forms Link to downloadable forms
Center for Medicare & Medicaid Services - Overview Link to general overview

Special Care Facilities

Special Care Facilities
Special Care Facility License Application Word File   PDF File   
Architectural Review Information and Forms
Directory of Special Care Facilities 
Excel File   PDF File  

Substance Abuse Facilities

Substance Abuse Facilities
Substance Abuse Facility License Application Word File      PDF File   
Substance Abuse Facility License Checklist Outpatient Applicant PDF File     Residential Applicant PDF File  
Substance Abuse Facility ADA Checklist  
Substance Abuse Facility Closure Information PDF File  
Court Commitment Application PDF File  
Helpful Phone Numbers PDF File  
Substance Abuse Licensed Sites/By City Order Excel File    PDF File  
Faith-based Exemption Registration Application Word File   PDF File    
Registered Exempt Faith-Based Programs PDF File  

 


Disclosure and Consent forms

Disclosure and Consent forms
Disclosure and Consent - Medical and Surgical Procedures - English Word File   PDF File   
Disclosure and Consent - Medical and Surgical Procedures - Spanish Word File   PDF File   
Disclosure and Consent - Radiation Therapy - English Word File    PDF File    
Disclosure and Consent - Radiation Therapy - Spanish Word File   PDF File   
Disclosure and Consent - Hysterectomy - English Word File   PDF File  
Disclosure and Consent - Hysterectomy - Spanish Word File   PDF File  
Disclosure and Consent – Anesthesia and/or Perioperative Pain Management (Analgesia) Word FIle         PDF File
Disclosure and Consent – Anesthesia and/or Perioperative Pain Management (Analgesia) – Spanish Word File     PDF File
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Last updated September 29, 2014