TX HHS Form 3205. End Stage Renal Disease Facility License Renewal Addendum

The TX HHS Form 3205, End Stage Renal Disease Facility License Renewal Addendum, is a crucial document for healthcare facilities that provide dialysis services to patients with end-stage renal disease. This form helps ensure compliance with licensing requirements and facilitates the renewal process for existing facilities seeking to continue providing these life-saving treatments.

This addendum requires facility administrators to provide detailed information about their services, personnel, and fire safety inspections. Key features include selecting the type of dialysis services offered, listing administrator contact details, and providing names and license numbers for medical directors, nurses, social workers, dietitians, and other essential staff members. Additionally, facilities must demonstrate Medicare certification by providing their CCN number.

Facilities seeking to renew their End Stage Renal Disease Facility License must complete this addendum as part of the renewal process. The form is typically filled out by facility administrators or designated representatives. To ensure compliance with licensing requirements, facilities should carefully review and complete all sections, including those related to services, personnel, and fire safety inspections.

• This form is used for End Stage Renal Disease Facility License Renewal Addendum purposes only.
• Facilities must provide detailed information about their services, personnel, and fire safety inspections.
• The addendum requires Medicare certification and CCN number submission.