TX HHS Form 6325. Home and Community Support Services Agency Medicare Certified Agency Relocation Questionnaire

The TX HHS Form 6325, "Home and Community Support Services Agency Medicare Certified Agency Relocation Questionnaire," is a crucial document that helps agencies relocate their Medicare certification while ensuring compliance with relevant regulations. This form should be used when an agency intends to transfer its license from one location to another, or change ownership while relocating.

The questionnaire requires the agency to provide information about the relocation, including whether they will serve the same population, utilize the same personnel, and offer the same services. The agency must also specify the counties they are relocating from and to, as well as confirm whether a corresponding 855 form has been submitted to their Medicare administrative contractor (MAC). Failure to complete this questionnaire could result in non-compliance with Texas Administrative Code Section 558.208 and 558.213(f).

This form is essential for determining the state's recommendation of approval or denial of the Medicare Certified agency relocation. If any of the questions 1-3 are answered "no," the state will recommend denying the relocation, as it would be considered a cessation of business (voluntary termination) according to CMS Admin Infor: 22-02-ALL. The TX HHS Form 6325, Home and Community Support Services Agency Medicare Certified Agency Relocation Questionnaire, is a critical tool for agencies seeking to relocate their Medicare certification while maintaining compliance with relevant regulations.