CHOW form docx 2025

1. Click ‘Get Form’ to open the CHOW form in the editor.
2. Begin by filling out the Previous Owner’s Information section. Enter the Previous Texas Provider Identifier (TPI) and both the Current and New Fiscal Year End dates.
3. Check the applicable reason for change of ownership, such as Change in Lease, Merger, or Termination. Then, provide the Effective Date of this change.
4. Indicate whether CMS considered this a change of ownership by selecting 'Yes' or 'No'. If 'Yes', complete all fields regarding the previous owner’s details including name, address, and contact information.
5. Proceed to the New Owner’s Information section. Answer if the new owner assumes liability and fill in their details including Medicare intermediary and Tax ID number.
6. Complete the Statement of Change of Ownership section by indicating whether the new owner accepts assets and liabilities from prior periods. Fill in all required statements accurately.

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