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Provider Change of Ownership Form - TMHP.com 2026
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- Click ‘Get Form’ to open the Provider Change of Ownership Form in our editor.
- Begin by filling out the 'Previous Owner’s Information' section. Enter the Previous Provider’s Texas Provider Identifier (TPI) and both the current and new fiscal year end dates.
- Circle the applicable reason for change of ownership, such as 'Change in Lease', 'Merger', or 'Termination'. Provide the effective date of the change.
- If CMS considered this a change of ownership, complete the required fields regarding the previous owner, including their name, address, tax ID number, and contact information.
- Next, move to the 'New Owner’s Information' section. Indicate whether the new owner assumes liability and provide their details including name, address, tax ID number, and contact information.
- Complete the 'Statement of Change of Ownership' section by selecting whether the new owner accepts assets and liabilities from prior periods. Sign and date where indicated.
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