TX HHS Form 3210. Ambulatory Surgical Center License Application

The TX HHS Form 3210, Ambulatory Surgical Center License Application, is a crucial document for healthcare providers seeking to establish or modify an ambulatory surgical center in Texas. This form helps solve the problem of obtaining the necessary license from the Texas Health and Human Services (HHS) to operate a facility that provides outpatient surgical services.

The application requires key information about the facility, including its doing business as (DBA) name, mailing address, city, state, and ZIP code. Additionally, the form seeks details on ownership, such as legal name, employer identification number (EIN), and type of entity (e.g., profit or nonprofit). Important sections include Facility Information and Ownership Information, which must be completed accurately to ensure a smooth application process.

This form is typically used by ambulatory surgical centers seeking initial licensure or changes to their existing license. It is essential for healthcare providers to carefully complete the application, providing all required information and supporting documents as specified in the instructions. By submitting this form, facilities can demonstrate compliance with Texas regulations and ensure they are properly licensed to operate.