TX HHS Form 3604-A. Ownership Transfer Affidavit Addendum for ICF/IID

The TX HHS Form 3604-A, Ownership Transfer Affidavit Addendum for ICF/IID, is a crucial document used to facilitate the transfer of ownership of an Intermediate Care Facility for Individuals with Intellectual Disability or Related Conditions (ICF/IID) provider agreement. This form helps solve the problem of assigning the provider agreement from one entity to another, ensuring continuity and compliance with Texas Administrative Code requirements.

This addendum requires key information, including the names of the assignor and assignee, the effective date of the assignment agreement, and the signatures of both parties. The form also includes important sections that outline the terms and conditions of the assignment, including the assignee's responsibility to fulfill all obligations under the provider agreement and their liability for any liabilities or obligations arising from acts or events prior to the effective date of the assignment.

The TX HHS Form 3604-A should be used when there is a change in ownership or management of an ICF/IID facility, as required by Texas Administrative Code. The form must be completed and submitted to the Texas Health and Human Services Commission (HHSC) along with the original Form 3604 and a copy, ensuring compliance with regulatory requirements.