The Texas Form 3703, officially known as the Application for Plan Review for a Nursing Facility, is an essential document for individuals or entities seeking to construct or modify a nursing facility within the state. As of September 2014, the form requires comprehensive details regarding the facility or project, including the name and physical address of the facility, contact information of the project's main contact person, and an estimate of the project's cost. It also inquires about the fire sprinkler system's installation. Applicant information is meticulously collected, detailing the owner or their contact, the architect firm involved, and any engineers' details, alongside their Texas registration numbers. This form segregates different types of applications such as new constructions, relocations, additions, and other modifications, requiring specific details about the nature of each project. Moreover, it categorizes facilities into single-story, multi-story, and specialized units like those certified for Alzheimer’s care, highlighting the capacity and security measures in place. Applicants must also navigate through the fee structures as determined by the Texas Administrative Code and submit all necessary information for processing. This critical document underscores the state's commitment to safeguarding the well-being of nursing facility residents through stringent planning and review processes.
| Question | Answer |
|---|---|
| Form Name | Texas Form 3703 |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | 3703 texas health and human services commission pobox 149055 form |
Application for Plan Review
for a Nursing Facility
Form 3703
September 2014
Service Code
324200100
LTC Review Fees
1.Facility/Project Information
Facility Name
Physical Address — Street |
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Facility/Project Contact Person |
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Facility/Project Contact Person’s Telephone Number |
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Project Cost Estimate |
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Is the facility to be completely fire sprinklered? |
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2. Applicant Information |
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Owner or Owner’s Contact Person |
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Internet Address |
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Address (if different than facility) |
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Architect Firm |
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Name of Architect |
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Project Manager |
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Engineering Firm |
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Name of Engineer |
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Project Manager |
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3. Type of Application (check all that apply)
Initial — New Construction |
Initial — Relocation (New Construction) |
Addition of Wing/Building/Area |
Describe: |
Laundry Kitchen Living/Dining Other:
Other details/description:
No. of Beds: |
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Number of beds before project:
Number of beds after project:
Have plans been previously submitted for this project?
Yes No
If Yes, when?
By whom?
4. Type of Facility (check all that apply)
Alzheimer’s Certified
Capacity: beds
Locked Area NOT Alzheimer’s Certified Describe:
Capacity: beds
5. Fees
Fee Enclosed (see Texas Administrative Code [TAC], Title 40, Pt. 1, Ch. 19, §19.219) Remitter Name (who signed check)
$ |
Check Number: |
Telephone Number
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Instructions for Completing Form 3703
Application for Plan Review for a Nursing Facility
PROCEDURE
Complete this form to apply for optional plan review services for a nursing facility.
Note: This application is for a plan review by the Texas Department of Aging and Disability Services (DADS). A separate application is required for licensure. This plan review does not satisfy the requirements for a plan review by the Texas Department of Licensing and Regulation (TDLR) for accessibility.
Mail attached payment coupon with fee to:
Texas Department of Aging and Disability Services
Regulatory Services
P.O. Box 149055, Mail Code
Austin, TX
Submit application and plans to:
Texas Department of Aging and Disability Services |
Phone: |
Long Term Care Regulatory |
Fax: |
Architectural Unit |
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Facility Enrollment, Mail Code |
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701 West 51st Street |
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Austin, TX 78751 |
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1.Facility/Project Information
•Facility Name — Enter the full name of the facility.
•Physical Address — Enter the address of the facility, including the city, state, ZIP code and county where the facility is physically located.
•Facility/Project Contact Person — Full name of the person in charge of the building project.
•Contact Person’s Title — Provide the facility/project contact person’s title.
•Facility/Project Contact Person’s Telephone Number — Provide the telephone number, including area code.
•Fax Number — Provide the facility/project contact person’s fax number, including area code.
•Internet Address — Provide the Internet address or email address of the facility/project contact person.
•Mailing Address — Provide the facility/project contact person’s mailing address, including city, state and ZIP code (if different from the physical address).
•Project Cost Estimate — Provide the estimated cost of the project in dollars.
•Is the facility to be completely fire sprinklered? — Check Yes or No.
2.Applicant Information
•Owner or Owner’s Contact Person — Provide the full name of the owner’s representative.
•Title — Provide the title of the owner’s representative.
•Telephone Number — Provide the owner’s representative’s telephone number, including area code.
•Internet Address — Provide the Internet address or email address of the owner’s representative.
•Fax Number — Provide the owner’s representative’s fax number, including area code.
•Address — Provide the address for the owner’s representative, including city, state and ZIP code (if different from the facility address).
•Architect Firm — Provide the name of the firm or individual who produced the construction documents.
•Telephone Number — Provide the architectural firm’s telephone number, including area code.
•Name of Architect — Provide the full name of the architect whose seal is affixed to the drawings.
•Texas Registration Number — Provide the architect’s registration number with the Texas Board of Architectural Examiners.
•Project Manager — Provide the full name of the architectural project manager in charge of the project.
•Title — Provide the architectural project manager’s title.
•Internet Address — Provide the Internet address or email address of the architect in charge of the project.
•Fax Number — Provide the architect’s fax number, including area code.
•Mailing Address — Provide the mailing address, including city, state and ZIP code, of the architect in charge of the project.
•Engineering Firm — Provide the full name of the firm or individual who produced the construction documents.
•Telephone Number — Provide the engineering firm’s telephone number, including area code.
Form 3703 — Instructions
Page
•Name of Engineer — Provide the full name of the engineer whose seal is affixed to the drawings.
•Texas Registration Number — Provide the engineer’s Texas registration number with the Texas Board of Professional Engineers.
•Project Manager — Provide the full name of the engineering project manager in charge of the project.
•Title — Provide the engineering project manager’s title.
•Internet Address — Provide the Internet address or email address of the engineer in charge of the project.
•Fax Number — Provide the engineer’s fax number, including area code.
•Mailing Address — Provide the mailing address, including city, state and ZIP code, of the engineer in charge of the project.
3.Type of Application
•Check the appropriate boxes for the type of application being submitted.
•“Initial” means new facility or the conversion of an existing building into a licensed facility.
•“Initial — Relocation” means relocating an existing licensed facility.
•“Addition of Wing/Building/Area” means making an addition to a licensed facility.
•Provide a
•“Laundry” means construction of a new laundry or renovation of or addition to an existing laundry in a licensed facility.
•“Kitchen” means construction of a new kitchen or renovation of or addition to an existing kitchen in a licensed facility.
•“Living/Dining” means construction of new living or dining space or renovation of or addition to an existing dining or living space in a licensed facility.
•Check the box for Other and enter a brief description of other items included in the project.
•No. of Beds — Provide the number of proposed beds for this project (for calculation of the plan review fee).
•Number of beds before project — Provide the licensed capacity (number of beds) before this project.
•Number of beds after project — Provide the proposed licensed capacity (number of beds) after this project.
•Have plans been previously submitted for this project? — Check Yes or No.
•If Yes, provide the date of last submittal and the remitter’s name.
4.Type of Facility
•Check the appropriate boxes for the type of facility being submitted.
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•“Alzheimer’s Certified” means a building, unit or wing that is certified to meet the requirements of 40 TAC §19.2208, Standards for Certified Alzheimer’s Facilities.
•Capacity — Provide the number of beds in the existing or proposed Alzheimer’s certified facility, unit or wing.
•“Locked Area NOT Alzheimer’s Certified” means a building, unit or wing that is locked for the protection of the residents.
•Describe the locked area.
•Capacity — Provide the number of beds in the existing or proposed locked area.
5.Fees
•Compute the fee from 40 TAC §19.219.
•Check Number — Provide the check number from the fee check.
•Remitter Name — Provide the full name of the person whose signature is on the fee check.
•Telephone Number — Provide the remitter’s telephone number, including area code.
§19.219 Plan Review Fees
(a)The Texas Department of Human Services (DHS) charges a fee to review plans for new buildings, additions, conversion of buildings not licensed by DHS, or remodeling of existing licensed facilities.
(b)The fee schedule follows:
(1)Facilities – new construction:
(A)
(B)
(2)Additions or remodeling of existing licensed facilities — 2% of construction cost with $500 minimum fee and a maximum not to exceed $2,000.
(3)Alzheimer's certification — $550 in addition to the fees specified in paragraphs
Payment Coupon for Facility Enrollment
Plan Review (324200100)
Facility Name and Address
Print Remitter’s Name (person signing check):
Make check or money order payable to:
Texas Department of Aging and Disability Services
Attach check or money order to this coupon and return to:
Texas Department of Aging and Disability Services
Regulatory Services
P.O. Box 149055, Mail Code
Austin, TX