TX HHS Form 3240. Limited Services Rural Hospital (LSRH) License Application

The TX HHS Form 3240, Limited Services Rural Hospital (LSRH) License Application, is a crucial document for hospitals seeking to obtain or renew an LSRH license in Texas. This form helps solve the problem of ensuring compliance with state and federal regulations for rural hospitals providing limited services.

This application requires key information such as the hospital's name, mailing address, and contact details. It also asks about ownership structure, including the legal name of the direct owner, their Employer Identification Number (EIN), and other relevant details. The form must be completed by a general or special hospital applying for an LSRH license, which meets all rule requirements under Texas Administrative Code Title 26 Chapter 511 and Code of Federal Regulations Title 42 Section 485 Subpart E.

The TX HHS Form 3240 is used when a rural hospital wants to apply for an initial LSRH license or reapply after operating under emergency rules. The form must be submitted with supporting documentation, including IRS letters assigning the EIN and organizational charts showing ownership structure, as per instructions. By using this form, hospitals can ensure compliance with regulatory requirements and obtain the necessary license to operate in Texas.