(2) Application requirements. The applicant
shall submit the information listed in subparagraph (C) of this paragraph to
the commission .
(A) An applicant shall not
misstate a material fact on any documents required to be submitted under this
subsection.
(B) The application
form shall be accurate and complete and shall contain original signatures. The
initial license fee shall accompany the application.
(C) The following documents shall be
submitted with the original application form prescribed by the commission and
shall be originals or notarized copies:
(i)
information on the applicant including name, street address, mailing address,
social security number or franchise tax identification number, date of birth,
and driver's license number;
(ii)
the name, mailing address, and street address of the abortion facility. The
street address provided on the application shall be the physical location from
which the abortion facility will be operating and providing services;
(iii) the telephone number of the facility,
the telephone number where the administrator can usually be reached when the
facility is closed, and if the facility has a fax machine, the fax
number;
(iv) a list of names and
business addresses of all persons who own any percentage interest in the
applicant including:
(I) each limited partner
and general partner if the applicant is a partnership; and
(II) each shareholder, member, director, and
officer if the applicant is a corporation, limited liability company, or other
business entity;
(v) a
list of any businesses with which the applicant subcontracts and in which the
persons listed under clause (iv) of this subparagraph hold any percentage of
the ownership;
(vi) if the
applicant has held or holds an abortion facility license or has been or is an
affiliate of another licensed facility, the relationship, including the name
and current or last mailing address and physical location of the other
facility, and the date such relationship commenced and, if applicable, the date
it was terminated;
(vii) if the
facility is operated by or proposed to be operated under a management contract,
the names and addresses of any person and organization having an ownership
interest of any percentage in the management company;
(viii) a notarized affidavit attesting that
the applicant is capable of meeting the requirements of this chapter;
(ix) an organizational structure of the
staffing for the abortion facility. The organizational structure shall include
full disclosure in writing of the names and addresses of all owners and persons
controlling any ownership interest in the abortion facility. In the case of
corporations, holding companies, partnerships, and similar organizations, the
names and addresses of officers, directors, and stockholders, both beneficial
and of record, when holding any percent, shall be disclosed. In the case of a
nonprofit corporation, the names and addresses of the officers and directors
shall be disclosed;
(x) the
name(s), address(es), and Texas physician license number(s) of the physician(s)
(including the facility's designated medical consultant), and all advanced
practice registered nurse(s) and physician assistant(s) who will provide
services at the abortion facility;
(xi) the following data concerning the
applicant, the applicant's affiliates, and the managers of the applicant:
(I) denial, suspension, probation, or
revocation of an abortion facility license in any state, a license for any
health care facility or a license for a home and community support services
agency (agency) in any state or any other enforcement action, such as (but not
limited to) court civil or criminal action in any state;
(II) denial, suspension, probation, or
revocation of or other enforcement action against an abortion facility license
in any state, a license for any health care facility in any state, or a license
for an agency in any state which is or was proposed by the licensing agency and
the status of the proposal;
(III)
surrendering a license before expiration of the license or allowing a license
to expire in lieu of the commission proceeding with enforcement
action;
(IV) federal or state (any
state) criminal felony arrests or convictions;
(V) Medicare or Medicaid sanctions or
penalties relating to the operation of a health care facility or
agency;
(VI) operation of a health
care facility or agency that has been decertified or terminated from
participation in any state under Medicare or Medicaid; or
(VII) debarment, exclusion, or contract
cancellation in any state from Medicare or Medicaid; and
(xii) for the two-year period preceding the
application date, the following data concerning the applicant, the applicant's
affiliates, and the managers of the applicant:
(I) federal or state (any state) criminal
misdemeanor arrests or convictions;
(II) federal or state (any state) tax
liens;
(III) unsatisfied final
judgments;
(IV) eviction involving
any property or space used as an abortion facility or health care facility in
any state;
(V) injunctive orders
from any court; or
(VI) unresolved
final Medicare or Medicaid audit exceptions.