TX HHS Form 3221. Health Care Facility Certification Under Executive Order GA-15

The TX HHS Form 3221, "Health Care Facility Certification Under Executive Order GA-15," is a certification form for licensed health care facilities in Texas. This form helps solve the problem of certifying compliance with specific conditions during the COVID-19 pandemic.

This form requires key information about each facility, including contact details, facility name and address, license number, and Medicare/CMS certification number. The certification process involves three main sections: individual contact information, facility information, and certification itself. Facilities must certify that they will reserve at least 25% of their hospital capacity for COVID-19 patients and not request personal protective equipment from public sources during the pandemic.

This form should be used by licensed health care facilities in Texas to demonstrate compliance with Executive Order GA-15, which prohibits non-medically necessary surgeries and procedures during a specified period. The certification must be submitted via email, updating the subject line with relevant facility information. By completing this form, facilities can ensure they meet the conditions outlined in the executive order.