Get Tx Dshs Abortion Facility License Application 2018-2025

The TX DSHS Abortion Facility License Application is essential for obtaining the necessary licensing for operating an abortion facility in Texas. This guide will provide step-by-step instructions to assist you in successfully completing the application online.

Follow the steps to complete the application process effectively.

1. Click ‘Get Form’ button to obtain the application form and access it in your preferred online format.
2. Begin by selecting whether this application is for an Initial License or a Change of Ownership (CHOW) license. Fill in the relevant projected or effective date of the facility's opening or ownership change.
3. In the Facility Information section, provide the Doing Business As (D/B/A) or Assumed Name of the facility, making sure it aligns with any advertisements or signage.
4. Enter the street and mailing addresses of the facility, ensuring all information is complete, including city, state, and zip code.
5. Complete the contact details section including telephone and fax numbers. If you do not have these numbers yet, you may leave them blank.
6. Proceed to the Ownership Information section. Here, indicate the Legal Name of the entity responsible for the facility’s operations, its mailing address, and EIN number. Ensure to match this information with IRS documentation.
7. In the Ownership and Control Interest Disclosure section, answer all questions regarding the owner/legal entity’s past activities. If applicable, provide additional details on a separate sheet.
8. In the Licensing Fee section, indicate the appropriate fee amount, $5,000.00, and ensure it is payable to the Texas Health and Human Services Commission. Note that the fee is non-refundable.
9. Provide names and identification numbers of all licensed professionals at the facility under the Personnel section.
10. Attach all required documents as specified. This includes organizational structures, tax documents, and for CHOW applications, a sale agreement.
11. Finally, the Administrator should sign and date the application, confirming that all information is accurate and complete. Include the administrator's contact details.
12. Once all sections are completed, save any changes made to the form, and choose options to download, print, or share the application as needed.

Begin filling out the TX DSHS Abortion Facility License Application online today to ensure compliance and timely submission.