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 that facilitates the transfer of ownership of an Intermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions (ICF/IID) provider agreement. This form helps resolve situations where the ownership of an ICF/IID facility changes hands, ensuring a smooth transition and compliance with Texas Administrative Code.

This addendum is used in situations where the assignor assigns their provider agreement to an assignee. The form requires key information, including the date of the assignment agreement, the names of the assignor and assignee, and their respective signatures and printed names. Additionally, the form outlines the responsibilities of the assignee, which include fulfilling all terms, conditions, and obligations under the provider agreement, as well as assuming any pending liabilities or obligations.

To complete this form, the assignor and assignee must provide their authorized signatures, printed names, and legal entity names. The completed Form 3604-A, along with a copy of the original and the completed Form 3604, Ownership Transfer Affidavit, should be mailed to the Texas Health and Human Services Commission (HHSC) or its successor agency. Key points to note include:

• The form is used for the transfer of ownership of an ICF/IID provider agreement.
• The assignee assumes responsibility for fulfilling all terms, conditions, and obligations under the provider agreement.
• The form requires the assignment agreement date, assignor and assignee names, signatures, and printed names.