TX HHS Form 1092. Change of Ownership Transfer Affidavit

The TX HHS Form 1092, Change of Ownership Transfer Affidavit, is a crucial document used to transfer operational functions of a facility from one owner to another. This form serves as an official declaration of the change in ownership, ensuring compliance with Texas Administrative Code (TAC) regulations.

This affidavit is designed for various types of healthcare providers, including nursing facilities, assisted living facilities, day activity and health services, prescribed pediatric extended care centers, intermediate care facilities for individuals with intellectual disabilities or related conditions, and home and community support services agencies. The form requires the outgoing owner to provide information about their facility, including name, license number, contract number, email address, and mailing address.

The TX HHS Form 1092 must be completed accurately and notarized before uploading it into the Texas Unified Licensure Information Portal (TULIP). Providers are also required to notify their contract manager if they have a contract with the Texas Health and Human Services Commission (HHSC). By using this form, healthcare providers can ensure a seamless transition of ownership and maintain compliance with state regulations.