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The Health Facility Program is within the Division for Regulatory Services.
Health Facility Licensing
Reference Center
Reference Center
Applications and Forms
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This page contains applications, forms and directories pertaining to facility licensure . Refer to File Viewing Information on the left-hand side menu to download viewers for PDF files, MS Word documents and Excel files.
- Abortion Facilities
- Ambulatory Surgical Centers
- Birthing Centers
- Community Mental Health Centers
- Comprehensive Out-Patient Rehabilitation Facilities
- End-Stage Renal Disease Facilities
- Hospitals - General & Special
- Hospitals - Psychiatric & Crisis Stabilization Units
- Laboratories - CLIA
- Narcotic Treatment Clinics
- Out-Patient Physical Therapy or Speech Pathology Services
- Portable X-Ray Services
- Rural Health Clinics
- Special Care Facilities
- Substance Abuse Facilities
- TMDP- Disclosure and Consent
Abortion Facilities
| How to Become a Licensed Abortion Facility Application | Word File 61KB |
PDF File 31KB |
| DSHS Vital Statistics Abortion report forms for physicians - Click here to link | ||
Disclosure and Consent form |
Locate PDF file at: 22 TAC §165.6(f) | |
| Informed Consent Certification form | TAC §139.52(a)(1) - English | |
| Affidavit of Age form | PDF File 7KB - Spanish | TAC ยง139.41(a)(8)(A) - English |
| Information on Toll-Free Telephone Number | TAC §139.6(a)(2) - Spanish | TAC §139.6(a)(1) - English |
Ambulatory Surgical Centers
| How to Become a Licensed Ambulatory Surgical Center Application |
Word File 61KB | PDF File 28KB |
| Architectural Review Information and Forms - Click here to link | ||
| Disclosure and Consent forms for medical and surgical procedures | ||
| Incident Report form | PDF File 12KB | |
| Annual Occurrence Report form | Word File 70KB | PDF File 40KB |
| Best Practices Report form | Word File 36KB | PDF File 35KB |
| Directories of Ambulatory Surgical Centers. Directories are updated on the 1st and 15th business day of each month. Revised date appears on first page of PDF listing. | Excel File 145KB | Alphabetical 69KB PDF By County 66KB PDF |
Birthing Centers
| How to Become a Licensed Birthing Center Application | Word File 58KB | PDF File 741KB |
| Directories of Birthing Centers Directories are updated on the 1st and 15th business day of each month. Revised date appears on first page of listing. |
Alphabetical 17KB PDF By County 33KB PDF |
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Community Mental Health Centers and
Comprehensive Out-Patient Rehabilitation Facilities
| Center for Medicare/Medicaid Services - Forms | Link to downloadable forms |
| Center for Medicare/Medicaid Services - Overview | Link to general overview page |
End Stage Renal Disease Facilities
| How to Become a Licensed End Stage Renal Disease Facility Application | Word File 80KB | PDF File 41KB |
| Architectural Review Information and Forms - Not mandatory for ESRDs - Click here to link | ||
| Incident Report including instructions | PDF File 32KB | |
| Application and Survey and Certification Report - CMS 3427- Link to downloadable forms | ||
Directories of End Stage Renal Disease Facilities |
Excel File 191KB |
Alphabetical By County |
Hospitals - General and Special
| How to Become a Licensed General or Special Hospital Application | Word File 236KB | PDF File |
| Architectural Review Information and Forms - Click here to link | ||
| Fire Safety Survey Report form | PDF File 39KB | |
| Annual Occurrence Report form | Word File 62KB | PDF File 30KB |
| Best Practices Report form | Word File 41KB | PDF File 28KB |
| Hospital Closure and Change of Ownership Instructions | PDF File 32KB | |
| Disclosure and Consent forms for medical and surgical procedures | ||
| Hospital Waiver Request | PDF File 37KB | |
| Directories of General & Special Hospitals
Directories are updated on the 1st and 15th business day of each month. Revised date appears on first page of PDF listing. |
Excel File 357KB | Alphabetical |
Hospitals - Psychiatric and Crisis Stabilization Units
| How to Become a Licensed Psychiatric Hospital or CSU Application | Word File 348KB | PDF File 119KB |
| Architectural Review Information and Forms - Click here to link | ||
| Fire Safety Survey Report form | PDF File 39KB | |
| Annual Occurrence Report form | Word 42KB | PDF File 39KB |
| Best Practices Report form | Word 37KB | PDF File 34KB |
| CSU Directory | PDF File 23KB | |
| Directories for Psychiatric Hospitals Directories are updated on the 1st and 15th business day of each month. Revised date appears on first page of listing. |
Excel File 21KB | Alphabetical 15KB PDF By County 32KB PDF |
Laboratories - CLIA
| Application for CLIA Certification and Overview- CMS Link |
| Fee Schedule Information - CMS Link |
Narcotic Treatment Clinics
| Application for Permit - Hospital Narcotic Drug Detoxification Treatment Medication Unit |
Word File 430 KB | PDF File40KB |
| Application Questionnaire - Hospital Narcotic Drug Detoxification Treatment Medication Unit |
Word File 433 KB | PDF File 39KB |
| Fee Submission Form- Narcotic Treatment Program | Word File 109 KB | PDF File 38KB |
| Narcotic Treatment Program List of Clinics | Excel File 29KB By Clinic Name |
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Out-Patient Physical Therapy | Speech Pathology Services |
Portable X-Ray Services | Rural Health Clinics
| Center for Medicare & Medicaid Services - Forms | Link to downloadable forms |
| Center for Medicare & Medicaid Services - Overview | Link to general overview |
Special Care Facilities
| Special Care Facility License Application | Word File 136KB | PDF File 123KB |
| Architectural Review Information and Forms - Click here to link | ||
| Directory of Special Care Facilities (Revised date appears on first page of listing) |
PDF File 19KB | |
Substance Abuse Facilities
| Substance Abuse Facility License Application | Word 555KB | PDF File 53KB |
| Substance Abuse Facility License Checklist | Word 34KB | PDF File 64KB |
| Substance Abuse Facility ADA Checklist. Click to link. | ||
| Substance Abuse Facility Closure Information | Word 32KB | PDF File 63KB |
| Court Commitment Application | Word 82KB | PDF File 37KB |
| Helpful Phone Numbers | Word 26KB | PDF File 11KB |
| Substance Abuse Licensed Sites/By City Order | PDF File 309KB | |
| Faith-based Exemption Registration Application | Word 26KB | PDF File 10KB |
| Faith-based Registered Exempt Directory Link | ||
Disclosure and Consent forms
| Disclosure and Consent - Medical and Surgical Procedures - English | Word File 26KB | PDF File 53KB |
| Disclosure and Consent - Medical and Surgical Procedures - Spanish | Word File 27KB | PDF File 58KB |
| Disclosure and Consent - Radiation Therapy - English | Word File 25KB | PDF File 58KB |
| Disclosure and Consent - Radiation Therapy - Spanish | Word File 26KB | PDF File 57KB |
| Disclosure and Consent - Hysterectomy - English | Word File 33KB | PDF File 75KB |
| Disclosure and Consent - Hysterectomy - Spanish | Word File 25KB | PDF File 71KB |
Back to the Top - Health Facility Program Home -- Site Map -- Links - Contact Us
Texas Department of State Health Services, Health Facillity Licensing Program
1100 West 49th Street - Austin, Texas 78756 - (512) 834-6646
Last Updated November 16, 2007
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