Texas Form 3703 – Fill Out and Use This PDF

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 E-411

Austin, TX 78714-9055

Submit application and plans to:

Texas Department of Aging and Disability Services	Phone: 512-438-2371
Long Term Care Regulatory	Fax: 512-438-4623
Architectural Unit
Facility Enrollment, Mail Code E-250
701 West 51st Street
Austin, TX 78751

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 2/09-2014

•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 one-sentence description of the addition.

•“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.

•“Single-story” means a building with one floor level at grade.

•“Multi-story” means a building with two or more floor levels, including basements.

•“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)single-story facilities — $20 per bed, $2,000 minimum; and

(B)multiple-story facilities — $24 per bed, $2,500 minimum.

(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 (1)-(2) of this subsection.

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 E-411

Austin, TX 78714-9055