TX HHS Form 3204. End Stage Renal Disease Facility License Application

The TX HHS Form 3204, End Stage Renal Disease Facility License Application, is a crucial document for healthcare facilities that provide dialysis services to patients with end-stage renal disease. This form helps facilities obtain the necessary license from Texas Health and Human Services (HHS) to operate legally.

This application requires facility information, including the doing business as (DBA) name, mailing address, and contact details. The form also collects ownership information, such as the legal name of the direct owner, employer identification number (EIN), and organizational chart showing the ownership structure. Facilities must select one type of license: initial, change of ownership, or relocation.

The TX HHS Form 3204 is essential for facilities seeking to establish a new dialysis center, acquire an existing facility, or relocate their operations. The form's instructions provide guidance on required attachments, including IRS letters and certificates from the Office of the Secretary of State. By completing this application, facilities can ensure compliance with Texas regulations and obtain the necessary license to operate a dialysis facility.