The Ambulatory Health Care Facility Attachment is a City of Dallas Development Services Department form. Its printed heading reads “Attachment to a Certificate of Occupancy Application for the Building Code Use: “Ambulatory Care Facility”.” Applicants for a Certificate of Occupancy (CO) for a doctor's office, dentist office, medical office or similar office use it to state where the tenant space is and how many patients could be rendered incapable of self-preservation. If you are looking for a Dallas permit form, note that this one travels with a CO application. On FillingPDF you can fill out the form online and download or print the completed PDF; the original is published by the City of Dallas at the link on this page.
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What is Ambulatory Health Care Facility Attachment – Dallas, TX?
The Ambulatory Health Care Facility Attachment is a City of Dallas Development Services Department form that a Certificate of Occupancy (CO) applicant signs to state whether the business is an “Ambulatory Care Facility” and how many patients it may render incapable of self-preservation.
The form quotes the 2021 Edition of the International Building Code definition: buildings or portions of buildings used to provide medical, surgical, psychiatric, nursing or similar care on a less than 24-hour basis to individuals who are rendered incapable of self-preservation. The definition may include colonic centers, dialysis centers, psychiatric centers, sedation dentistry and surgery centers. The form points to the life safety requirements for an “Ambulatory Care Facility” on an attached page (Section 422).
The form captures any new or pre-existing conditions of the business model with the CO application. It records the nonconforming elements of the building code, and the form states that use must have been continuous. The statements you make become conditions on any CO that is issued.
The code requirements are prospective: they apply to a new “Ambulatory Care Facility” or a newly expanded one, and they do not affect legal existing businesses that may require a new CO. The form is an attachment, not a stand-alone application, and it does not itself grant a CO.
Who needs to file Ambulatory Health Care Facility Attachment – Dallas, TX?
An applicant for a Certificate of Occupancy for any doctor's office, dentist office, medical office or other similar office must execute this form with the CO application. The form is signed by the tenant or owner.
Each applicant completes the part that matches the business:
- Ambulatory Care Facility with a tenant space on the ground floor.
- Ambulatory Care Facility with a tenant space that is not on the ground floor.
- Not applicable, or a facility not classified as an Ambulatory Care Facility, that will not render any person or patient incapable of self-preservation for any amount of time.
Legal existing businesses that need a new CO are not subject to the new code requirements, but the form still captures their nonconforming elements, and the use must have been continuous. A business whose use changes in character, for example by increasing the number of persons or patients affected by treatment so that the building code requirements may be triggered, needs a new CO and must comply with the building code requirements. The form does not describe signing through a representative.
When to file Ambulatory Health Care Facility Attachment – Dallas, TX
Submit the form with your Certificate of Occupancy application: the form states that an applicant must execute it with any CO application for a doctor's office, dentist office, medical office or similar office. It prints no separate due date.
The code requirements are prospective for any new or newly expanded “Ambulatory Care Facility”. A later change in the character of the use, such as a change in the number of persons or patients affected by treatment that may trigger the building code requirements, requires a new CO and compliance with those requirements. In the certification you also attest that, if changes increase the number of patients who could be rendered incapable of self-preservation, the facility must be made to comply with the currently adopted code.
How to fill out Ambulatory Health Care Facility Attachment – Dallas, TX
Read the Ambulatory Care Facility definition
Review the 2021 International Building Code definition printed at the top and the Section 422 life safety requirements on the attached page, so you know whether your use is an “Ambulatory Care Facility”.
Decide where your tenant space is
Check whether your tenant space is on the ground floor or not. You must make a check mark for both tenant space location and number of persons, or for Not Applicable.
Complete the ground floor section
If you are on the ground floor, check only one box: a maximum of 3 persons or patients who may be incapable of self-preservation for any amount of time, or more than 3.
Complete the not-ground-floor section
If you are not on the ground floor, check only one box: no patients rendered incapable of self-preservation for any amount of time, or one or more patients rendered incapable of self-preservation.
Use the Not Applicable section if it fits
If you are not an Ambulatory Care Facility as defined, check the box stating that you will not render any person or patient incapable of self-preservation for any amount of time.
Enter the suite and address
In the certification sentence, enter the Suite (address) of the location of the CO application.
Enter the original C.O. number
Enter the C.O. number under which the initial establishment of this use occurred, in the blank provided in the same certification sentence.
Print the tenant or owner name and date
In the Acknowledgement block, write the Printed Name of Tenant/Owner and the Date.
Sign as tenant or owner
Sign on the Signature of Tenant/Owner line. By signing you attest that your answers are accurate and that increasing the number of patients rendered incapable of self-preservation requires compliance with the currently adopted code.
Review and download the completed PDF
Check that only one box is marked in the section you used and that the address, C.O. number, name, date and signature are complete. Download or print the completed PDF from FillingPDF and include it with your CO application.
How to submit Ambulatory Health Care Facility Attachment – Dallas, TX
The form goes in with your Certificate of Occupancy application: it is an attachment to that application, and it names no separate address, portal or appointment process.
- With the CO application: include the signed attachment in the package you submit for the CO, using the channel the City of Dallas Development Services Department gives for that application.
- Department contact printed on the form: Development Services Department, 320 E Jefferson Blvd, Dallas TX 75203, (214) 948-4480. Contact the department to confirm how and where to submit the CO application.
The form states that your answers become conditions on any issued CO, so check them before you submit. The form mentions no fee. FillingPDF lets you fill out and download the PDF; submission follows the channels above.
Common mistakes to avoid
- Checking more than one box in the ground-floor or not-ground-floor section; the form says to check only one.
- Marking only the tenant space location, or only the number of persons, when the form asks for a check mark for both, or for Not Applicable.
- Using the Not Applicable box while the business will render a person or patient incapable of self-preservation for any amount of time.
- Entering the wrong ground-floor answer by mixing up the two options: a maximum of 3 patients incapable of self-preservation, versus more than 3.
- Leaving the printed name, signature or date of the tenant or owner blank in the Acknowledgement block.
- Assuming the requirements never apply later: an increase in the number of patients that could be rendered incapable of self-preservation requires compliance with the currently adopted code.
- Describing a business as existing when its use has not been continuous; the form says use must have been continuous for nonconforming elements to be captured.
Frequently asked questions
What is the Ambulatory Health Care Facility Attachment?
It is a City of Dallas Development Services Department form attached to a Certificate of Occupancy application. You use it to state whether your business is an “Ambulatory Care Facility” and how many patients could be rendered incapable of self-preservation.
Do I need this form for a dentist or doctor's office in Dallas?
Yes, if you are applying for a Certificate of Occupancy. The form says an applicant must execute it with any CO application for any doctor's office, dentist office, medical office or other similar office.
Does the ambulatory care facility attachment apply to existing businesses?
The code requirements do not affect legal existing businesses that may require a new CO, but the form still captures the nonconforming elements and the use must have been continuous. A change in the character of the use requires a new CO and code compliance.
Which box do I check if my office is on the ground floor?
Check only one ground-floor box: a maximum of 3 persons or patients who may be incapable of self-preservation for any amount of time, or more than 3. If you are not an Ambulatory Care Facility as defined, use the Not Applicable box instead.
Where do I submit the Ambulatory Health Care Facility Attachment?
Submit it with your Certificate of Occupancy application. The form names no separate channel. It prints the Development Services Department address, 320 E Jefferson Blvd, Dallas TX 75203, and phone number, (214) 948-4480, for questions.
Who signs the form?
The tenant or owner signs in the Acknowledgement block, after writing a printed name and the date. By signing, you attest that the answers are accurate and that increasing the patients rendered incapable of self-preservation requires compliance with current code.
What happens if I later increase the number of patients?
You must make the facility comply with the currently adopted code. The form states this in the attestation, and it adds that a change in the number of patients that may trigger the building code requirements requires a new CO.
Can I fill out this Dallas form online?
You can fill out the PDF online on FillingPDF and download or print it. FillingPDF is an independent service, not connected to the City of Dallas, and does not submit the form; you include it with your CO application.
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