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 individuals or organizations contemplating a change of ownership in a healthcare facility. This form helps ensure compliance with Medicare certification requirements by providing a clear indication of the prospective owner's intentions regarding participation in the Medicare program.

The form requires the prospective owner to indicate their understanding of Medicare certification options and procedures, including notification of the Centers for Medicaid and Medicare Services (CMS) as mandated by 42 CFR §489.18(b). Key features of this form include the provision of required information such as the name of the previous owner, facility, and Medicare provider number, as well as the prospective owner's intentions regarding participation in the Medicare program.

To complete this form, the prospective owner must provide their legal entity name, facility name, and contact information. The form also outlines specific procedures for notification and follow-up actions, including submission to the Texas Health and Human Services Commission Regulatory Services (E-342) PO Box 149030 Austin, TX 78714-9030.

• This form is typically used in situations where a change of ownership is contemplated or negotiated in a healthcare facility.
• The prospective owner must notify CMS as mandated by 42 CFR §489.18(b).
• The form requires the prospective owner to indicate their intentions regarding participation in the Medicare program.