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

The Texas Health Care Facility Certification Form 3221 (TX HHS Form 3221) is used to certify health care facilities under Executive Order GA-15. This form helps solve the problem of ensuring that licensed health care facilities comply with COVID-19-related restrictions on surgeries and procedures.

This form requires facilities to provide contact information, facility details, and certification statements. Key features include the requirement for facilities to reserve at least 25% of their hospital capacity for treatment of COVID-19 patients and not request personal protective equipment from public sources during the pandemic. Facilities must also certify that all information on the form is correct and that they will comply with the conditions outlined in Executive Order GA-15.

When submitting this form, facilities receive acknowledgement via email regarding receipt of the certification. The "Submit by Email" button allows facilities to update the subject line of their email with relevant facility license number, type, and name information for each facility submitting the certification. By completing this form, health care facilities demonstrate their commitment to complying with COVID-19-related restrictions and ensuring patient safety.

• This form is used by licensed health care facilities in Texas during the COVID-19 pandemic.
• The form requires facilities to certify that they will reserve at least 25% of their hospital capacity for treatment of COVID-19 patients.
• Facilities must also certify that they will not request personal protective equipment from public sources during the pandemic.