Provider Change of Ownership Form - TMHP.com 2026

1. Click ‘Get Form’ to open the Provider Change of Ownership Form in our editor.
2. 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.
3. Circle the applicable reason for change of ownership, such as 'Change in Lease', 'Merger', or 'Termination'. Provide the effective date of the change.
4. 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.
5. 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.
6. 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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