TX HHS Form 3695. Prospective Owner Intentions Regarding Medicare Certification

The TX HHS Form 3695, "Prospective Owner Intentions Regarding Medicare Certification," is a crucial document for healthcare providers contemplating or negotiating a change of ownership. This form helps facilitate the process by requiring prospective owners to indicate their intentions regarding participation in the Medicare program.

To complete this form, prospective owners must provide essential information, including the name of the previous owner, facility, and Medicare provider number. They must also specify whether they intend to participate in the Medicare program, accept assignment of the previous owner's provider agreement, or apply for a new provider agreement. The Centers for Medicaid and Medicare Services (CMS) requires notification of any change of ownership, as outlined in 42 CFR §489.18(b).

This form should be used by healthcare providers who are considering a change of ownership, including those contemplating the sale or transfer of their facility. It is essential to complete this form accurately and submit it to Texas Health and Human Services Commission Regulatory Services (E-342) PO Box 149030 Austin, TX 78714-9030 as soon as possible. The form number and full title should be included on all submissions.