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 questionnaire is used in situations where an agency is relocating its license, renewing its application, or changing ownership while relocating.

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

The information provided in this questionnaire will be used by the state to determine approval or denial of the Medicare certified agency relocation. If the answers to questions 1-3 are "no," the state will recommend denial of the relocation. The form also highlights the importance of submitting an amended 855A form to the MAC and emphasizes that if a provider relocates and is no longer the same provider, it may be considered a cessation of business (voluntary termination) and only allowed to operate as a licensed HCSSA.

• The questionnaire is used for agency relocation, renewal applications, or change of ownership applications while relocating.
• The form requires information on population served, personnel utilized, and services offered after relocation.
• Submission of the corresponding 855 form to the MAC is required.