Contents
Form Example
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 |
City |
|
|
|
State |
ZIP |
|
County |
||
|
|
|
|
|
|
|
|
|
||
Facility/Project Contact Person |
|
|
|
|
|
Contact Person’s Title |
||||
|
|
|
|
|
|
|
|
|
||
Facility/Project Contact Person’s Telephone Number |
Fax Number |
|
|
|
Internet Address |
|
|
|||
( |
) |
( |
) |
|
|
|
|
|
|
|
Mailing Address (if different from physical address) — Street or P.O. Box |
City |
|
|
|
State |
|
ZIP |
|||
|
|
|
|
|
|
|||||
Project Cost Estimate |
|
|
Is the facility to be completely fire sprinklered? |
|||||||
$ |
|
|
|
Yes |
No |
|
|
|||
2. Applicant Information |
|
|
|
|
|
|
|
|
|
|
Owner or Owner’s Contact Person |
|
|
Title |
|
|
|
Telephone Number |
|||
|
|
|
|
|
|
( |
) |
|
||
Internet Address |
|
|
|
|
|
|
Fax Number |
|||
|
|
|
|
|
|
( |
) |
|
||
Address (if different than facility) |
|
|
City |
|
|
|
State |
|
ZIP |
|
|
|
|
|
|
|
|
|
|
||
Architect Firm |
|
|
|
|
|
|
Telephone Number |
|||
|
|
|
|
|
|
( |
) |
|
||
Name of Architect |
|
|
|
|
|
|
Texas Registration Number |
|||
|
|
|
|
|
|
|
|
|
|
|
Project Manager |
|
|
|
|
|
|
Title |
|
|
|
|
|
|
|
|
|
|
|
|||
Internet Address |
|
|
|
|
|
|
Fax Number |
|||
|
|
|
|
|
|
( |
) |
|
||
Mailing Address |
|
|
City |
|
|
|
State |
|
ZIP |
|
|
|
|
|
|
|
|
|
|
||
Engineering Firm |
|
|
|
|
|
|
Telephone Number |
|||
|
|
|
|
|
|
( |
) |
|
||
Name of Engineer |
|
|
|
|
|
|
Texas Registration Number |
|||
|
|
|
|
|
|
|
|
|
|
|
Project Manager |
|
|
|
|
|
|
Title |
|
|
|
|
|
|
|
|
|
|
|
|||
Internet Address |
|
|
|
|
|
|
Fax Number |
|||
|
|
|
|
|
|
( |
) |
|
||
Mailing Address |
|
|
City |
|
|
|
State |
|
ZIP |
|
|
|
|
|
|
|
|
|
|
|
|
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: |
|
(for fee purposes) |
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
()
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 |
|
Facility Enrollment, Mail Code |
|
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
•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.
•
•
•“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
More PDF Templates
Class Forms - Recording the schedule of services is a critical aspect of the Texas 3599 documentation.
Ut Forms - Ensure your authorized person brings their ID when picking up your transcript.
Basic Tb Questionnaire Form - Each completed form contributes to maintaining the standards of organic agriculture in the state.
Common mistakes
-
Incomplete Facility/Project Information: Many applicants fail to provide all necessary details about the facility, such as the full facility name, complete physical address, and contact information for the project contact person. Omitting any of these details can lead to delays in processing the application.
-
Incorrect Applicant Information: It is crucial to ensure that the owner’s contact information is accurate. Applicants often make mistakes in providing the owner’s name, title, or telephone number, which can complicate communication.
-
Failure to Specify Project Cost: Applicants sometimes neglect to include an estimated project cost. This information is essential for determining the appropriate fees and processing the application effectively.
-
Missing Application Type: Selecting the correct type of application is vital. Some individuals fail to check the appropriate boxes, which can lead to confusion about the nature of the project being proposed.
-
Inaccurate Bed Count: Providing incorrect numbers regarding the existing and proposed bed counts is a common mistake. This information is critical for fee calculations and regulatory compliance.
-
Omitting Previous Submission Details: If plans have been submitted before, failing to indicate this and provide the relevant details can hinder the review process. It is important to disclose any prior submissions.
-
Neglecting to Include Fees: Applicants often forget to include the necessary fees or fail to provide the correct check number and remitter name. Without this information, the application cannot be processed.
-
Ignoring Submission Instructions: Many applicants overlook the specific mailing instructions for both the application and payment. Following the outlined procedures is essential to ensure that the application is received and processed in a timely manner.
Key takeaways
Understanding the Texas 3703 form is essential for anyone involved in the planning or renovation of nursing facilities. Here are key takeaways to consider:
- Accurate Information is Crucial: Ensure that all facility and applicant information is filled out completely and accurately. This includes names, addresses, and contact details.
- Check the Application Type: Clearly indicate the type of application you are submitting, whether it’s for new construction, relocation, or an addition. This classification affects the review process.
- Fee Calculation: Be aware of the fee structure based on the type of facility and the scope of the project. Fees vary significantly between single-story and multi-story facilities.
- Fire Sprinkler Requirement: Specify whether the facility will be completely fire sprinklered. This detail is important for safety compliance and can impact the review process.
- Previous Submissions: If plans have been submitted before, indicate this on the form. Providing the date and the name of the remitter helps streamline the review.
- Separate Applications: Remember that this form is specifically for plan review and does not cover licensing requirements. A separate application is necessary for that purpose.
- Submission Process: After completing the form, mail it along with the required payment to the designated address. Ensure that all documents are sent to avoid delays in processing.
Completing the Texas 3703 form accurately and thoroughly can significantly influence the timely approval of your nursing facility project. Take these steps seriously to facilitate a smooth review process.
Steps to Using Texas 3703
Filling out the Texas 3703 form is an essential step for those looking to apply for a plan review for a nursing facility. After completing the form, you will submit it along with any required fees to the appropriate department. Make sure all information is accurate and complete to avoid delays in processing your application.
- Facility/Project Information:
- Enter the full name of the facility.
- Provide the physical address, including street, city, state, ZIP code, and county.
- List the contact person’s full name, title, telephone number, fax number, and email address.
- If the mailing address is different, include that information as well.
- Estimate the project cost and indicate if the facility will be completely fire sprinklered by checking Yes or No.
- Applicant Information:
- Provide the owner or owner’s contact person’s full name and title.
- List their telephone number, email address, and fax number.
- Include the address for the owner’s representative if different from the facility.
- Provide the name of the architect firm, their telephone number, and the architect’s full name and Texas registration number.
- List the project manager’s name, title, email address, fax number, and mailing address.
- Repeat similar steps for the engineering firm, including their name, telephone number, engineer’s name and registration number, project manager details, and mailing address.
- Type of Application:
- Check the appropriate boxes for the type of application: Initial, Relocation, or Addition.
- Provide a brief description of any addition.
- Indicate the number of proposed beds, the number of beds before the project, and the number after.
- State whether plans have been previously submitted for this project and provide details if applicable.
- Type of Facility:
- Check the boxes that apply: Single-story or Multi-story.
- Indicate if the facility is Alzheimer’s certified and provide the capacity.
- For locked areas not certified, describe the area and provide the capacity.
- Fees:
- Compute the fee based on the guidelines provided.
- Provide the check number, remitter’s name, and their telephone number.