Hhsctexas nursing facility form 3722 change of administrator-2026

1. Click ‘Get Form’ to open the hhsctexas nursing facility form 3722 in the editor.
2. Begin by entering the Facility Name and Facility ID No. in the designated fields at the top of the form.
3. Specify the Effective Date of Change, ensuring it aligns with your administrative transition timeline.
4. Fill in the Physical Address, including Street, City, State, and ZIP code, along with the County and Facility Telephone No.
5. Provide details for the new administrator: enter their Name (including title), Social Security No., and Administrator License No. Make sure to attach a current renewal card if applicable.
6. Complete both Permanent and Mailing Addresses for the new administrator, ensuring accuracy for correspondence.
7. Indicate the Fee Enclosed by entering $20.00 in the appropriate field and ensure payment is made payable to Texas Department of Aging and Disability Services.
8. Finally, sign as Owner/Applicant or Authorized Representative and have your signature notarized before submission.

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