TX HHS Form 3209. Chemical Dependency Treatment Facility Licensure Application Checklist for Change in Status Applicants

Form 3209 is an official checklist used by chemical dependency treatment facilities in Texas that are already licensed and need to request a change in their licensure status. This document guides applicants through the required steps and supporting materials necessary when adding a new site, modifying an existing facility, or adjusting approved services. It ensures that the Texas Health and Human Services Commission (HHSC) receives a complete submission that complies with Texas Administrative Code Title 25, Section 448.405.

The checklist accompanies the main application form (Form 3207) and helps providers confirm that all documents, fees, and supplemental records are included. Completing and submitting Form 3209 correctly helps avoid delays in processing and ensures that HHSC has adequate time for review.

Purpose of the Checklist

Form 3209 is required for any licensed chemical dependency treatment facility in Texas that intends to:

• Add a new facility site
• Make changes to an existing licensed facility
• Modify treatment services or operational details

Because changes in status involve regulatory compliance, inspections, and approvals, this checklist ensures the applicant submits all mandatory documentation according to state rules.

Where to Submit the Application

Completed applications, all required supporting documents, and the associated fees must be mailed to:

Texas Health and Human Services Commission
AR Mail Code 1470
P.O. Box 149055
Austin, Texas 78714-9055

Checklist for Change in Status – New Site Applicants

Facilities adding a new treatment site must submit an extensive list of documents to demonstrate legal, operational, and safety compliance. Required items include:

Core Application Items

• Completed Form 3207, Chemical Dependency Treatment Facility License Application
• Full payment of required license fees (non-refundable; cashier’s check or money order payable to HHSC)
• IRS letter assigning the Federal Employer Identification Number (FEIN)
• Certificate of Filing or certificate of status from the Secretary of State
• Assumed Name Certificate, if the facility operates under an assumed name

Operational and Compliance Documentation

• Facility’s Operational Plan (as described in 25 TAC Section 448.502)
• Proof of liability insurance showing the legal entity name and site address
• ADA Checklist – a comprehensive 89-page accessibility checklist for each building or suite
• Certificate of Occupancy or documentation stating the locality does not issue such certificates
• Lease agreement or deed showing the applicant’s legal name
• A detailed floor plan with clearly labeled rooms
• Co-location list identifying all non-substance use disorder services offered at the site, if applicable

Additional Requirements for Detoxification Facilities

• Name and license number of the medical director (required by 25 TAC Section 448.902)

Additional Requirements for Residential Facilities

Residential chemical dependency treatment facilities must undergo multiple safety and environmental inspections prior to licensure. Required documentation includes:

• Fire safety inspection by a certified fire inspector or the state fire marshal
• Inspection of the alarm system by an authorized specialist
• Kitchen health inspection by the local health authority or HHSC
• Gas pipe pressure test performed by a licensed plumber or gas company
• Inspection and maintenance records for fire extinguishers
• Fire alarm installation certificate issued by a state-registered fire alarm installer
• A floor plan specifying total square footage, room layout, and bed types for client sleeping areas

Checklist for Change in Status – Treatment Service Changes

Facilities modifying the type or scope of treatment services must also submit supporting documentation showing compliance with state regulations. Required items include:

• Completed Form 3207
• Payment of applicable license fees
• Updated Facility Operational Plan
• Co-location list for any non-substance use disorder services offered at the site

If a facility does not submit all required documentation within six months, HHSC may deny the application. After denial, the facility must wait six months before reapplying.

Regulatory Notes

A license issued under Chapter 464 of the Texas Health and Safety Code and 25 TAC Chapter 448 applies only to chemical dependency treatment facility operations. It does not replace or satisfy any other licensing requirements the facility may need to operate legally.

Applicant Acknowledgment and Signature

The form includes an acknowledgment section where the applicant confirms that the submission includes all required documents and that all information is accurate. The CEO or facility contact must sign and date the form, attesting to compliance with state laws and administrative rules.

Form Details

• Form Name: Chemical Dependency Treatment Facility License Application Checklist for Change in Status
• Form Number: 3209
• Service Code: 529201043
• Issuing Agency: Texas Health and Human Services Commission
• Region: State of Texas
• Revision Date: December 2022