Texas Health and Human Services

This addendum is an essential part of the birthing center license renewal process. While the core license application verifies the facility’s existence and compliance, this document focuses specifically on the qualifications of clinical staff and the center’s internal readiness to continue operations safely. In practice, this form helps the licensing authority confirm that the facility still employs appropriately licensed professionals and has a realistic continuity plan in case services must be suspended.

The TX HHS Form 3214, Chemical Dependency Treatment Facility Satellite Site Notification, helps chemical dependency treatment facilities (CDTFs) comply with licensing requirements by notifying the Texas Health and Human Services Commission (HHS) of satellite site operations. This form is used to report the establishment or closure of a satellite site, ensuring that services are provided under the supervision of a licensed outpatient care facility.

Form 3204 is the official application used to obtain, transfer, or relocate a license for an End Stage Renal Disease (ESRD) facility in Texas. This document is required for any organization that intends to operate a dialysis center, whether it provides in-center hemodialysis, home dialysis training, or pediatric services. Because dialysis facilities handle life-sustaining treatment for patients with kidney failure, the Texas Health and Human Services Commission (HHSC) requires detailed disclosure about ownership, personnel, facility readiness, and compliance history.

Form 3086 is the official End of Year Report used by entities participating in the Texas County Indigent Health Care Program (CIHCP). This document provides a standardized way for counties, public hospitals, and hospital districts to report annual data on clients served, expenditures, diagnoses, and program eligibility criteria. The form covers the state fiscal year from September 1 through August 31 and is essential for compliance, funding tracking, and statewide program evaluation.

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 TX HHS Form 3036, Preauthorization Request for Conversion Services, is a crucial document that helps facilitate the conversion process of adult mental health services. This form is typically completed by healthcare providers or organizations seeking preauthorization for behavioral health services under the Adult Mental Health (HCBS-AMH) Program.

The TX HHS Form 3037, Good Faith Effort, is a crucial document for HCBS-AMH Provider Agencies in Texas. This form helps solve the problem of identifying critical services that cannot be secured directly or through subcontracting, which is essential for maintaining successful placement in the community.

The TX HHS Form 3038, Children's Autism Program Family Cost Share Attestation Worksheet, helps families determine their cost share for autism services. This form is used to calculate the family's annual income and deductions, ensuring accurate determination of their financial responsibility. Typically, parents or guardians complete this form in conjunction with a contractor to attest that the provided information is correct.

The TX HHS Form 3041, MH Adult Uniform Assessment for Texas Resilience and Recovery, is a crucial tool for healthcare professionals to assess the needs and strengths of adult patients. This form helps solve the problem of determining the appropriate level of care for individuals experiencing mental health crises or requiring ongoing treatment. Typically filled out by Licensed Professional Counselors (LPCs) or Qualified Mental Health Professionals (QMHP), this assessment is used in situations where patients require crisis intervention, initial evaluation, updates, or discharge planning.

The TX HHS Form 3042, MH Child and Adolescent Needs and Strengths (CANS) Ages 3 through 5, is a practical tool designed to assess the needs and strengths of children aged 3-5. This form helps solve the problem of identifying potential risks and areas of support for young children, making it an essential resource for caregivers, educators, and healthcare professionals.