TX HHS Form 3604. Ownership Transfer Affidavit

The TX HHS Form 3604, Ownership Transfer Affidavit, is a crucial document used to facilitate the transfer of ownership or operational functions of a facility from one legal entity to another. This form helps solve the problem of ensuring a seamless transition of responsibility and liability between outgoing and incoming owners.

This form requires key information such as the name of the legal entity responsible for operations, facility name (doing business as), and dates of transfer. The document also highlights important sections, including the effective date of change and the date of official recognition by Texas Health and Human Services Commission (HHSC). Common scenarios of use include situations where a facility changes ownership or operational functions.

When completing this form, it is essential to provide accurate information and have it notarized. The completed original and one copy should be mailed to the address provided: Texas Health and Human Services Commission or Regulatory Services (for overnight shipments only). This form is an essential tool for ensuring a smooth transition of ownership and operational responsibilities.