The Texas 3703 form is the Application for Plan Review for a Nursing Facility. This form is required for facilities seeking optional plan review services from the Texas Department of Aging and Disability Services (DADS). It is essential for ensuring compliance with state regulations regarding nursing facility construction and modifications.
The Texas 3703 form, officially titled the Application for Plan Review for a Nursing Facility, serves as a critical tool for ensuring that new nursing facilities or modifications to existing ones meet the necessary regulatory standards. This form, which has been in use since September 2014, requires detailed information about the facility, including its name, physical address, and the contact person responsible for the project. It also gathers essential applicant information, such as the owner’s details and the architectural and engineering firms involved. Notably, the form distinguishes between various types of applications, such as initial construction or relocation, and allows for the specification of project details, including the number of beds and whether the facility will be fully equipped with fire sprinklers. Additionally, the Texas 3703 form outlines the fee structure associated with the plan review process, which varies based on the type of facility and the scope of the project. Completing this form accurately is essential, as it initiates the review process by the Texas Department of Aging and Disability Services, thereby ensuring compliance with state regulations and ultimately safeguarding the well-being of future residents.
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
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
Address (if different than facility)
Architect Firm
Name of Architect
Texas Registration Number
Project Manager
Mailing Address
Engineering Firm
Name of Engineer
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)
Single-story
Multi-story; Total no. of floors:
Alzheimer’s Certified
Capacity: beds
Locked Area NOT Alzheimer’s Certified Describe:
5. Fees
Fee Enclosed (see Texas Administrative Code [TAC], Title 40, Pt. 1, Ch. 19, §19.219) Remitter Name (who signed check)
Check 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 E-411
Austin, TX 78714-9055
Submit application and plans to:
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
•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:
Attach check or money order to this coupon and return to:
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