TX HHS Form 3604. Ownership Transfer Affidavit

The TX HHS Form 3604, Ownership Transfer Affidavit, is a crucial document that facilitates the transfer of ownership or responsibility for a facility's operations. This form helps solve the problem of ensuring a seamless transition of operational functions between outgoing and incoming owners. It is typically used in situations where there is a change in ownership or management of a facility regulated by the Texas Health and Human Services Commission (HHS). The form is completed by both the outgoing and incoming owners, who must provide required information about their entities and the transfer of operational functions.

The form requires key details such as the names of the legal entities responsible for operations, facility names, dates of transfer, and addresses. It also outlines conditions and responsibilities, including the outgoing owner's obligation to HHSC for any overpayments or underpayments that may have accrued during their period of ownership. The form emphasizes the importance of official recognition by HHSC and provides instructions for the incoming owner to obtain a new contract.

To complete the form, both owners must provide signatures from authorized representatives, along with a notarized copy. The completed form is then mailed to the Texas Health and Human Services Commission or its Regulatory Services department. Key points to note include:

• The form is used for ownership transfers of facilities regulated by HHS.
• The outgoing owner is responsible for any overpayments or underpayments that may have accrued during their period of ownership.
• The incoming owner must obtain a new, fully executed contract with HHSC before receiving contractor payments.