Provider Change of Ownership Form - TMHP.com 2025

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4.7 out of 5

52 votes

The document outlines the procedures and requirements for a change of ownership in a healthcare facility, as mandated by CMS and DSHS. It specifies that Medicare eligibility remains intact, allowing continued Medicaid participation if new owners fulfill certain obligations, including recertification, completing enrollment forms, and providing necessary documentation. Additionally, it includes a questionnaire to gather information about both previous and new owners to facilitate the ownership transition.

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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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How do I contact Medicaid provider enrollment in Missouri?

If you have questions or need assistance completing the enrollment forms, contact the Provider Enrollment Unit by e-mail at MMAC.providerenrollment@dss.mo.gov . For questions regarding billing, contact the Provider Communications Unit at 573-751-2896.

How do I contact AHCCCs provider enrollment?

For assistance on requesting the temporary 14-digit application ID or requesting domain permission, please contact AHCCCS Provider Assistance at 602-417-7670, option 5, or email AHCCCS Provider Enrollment at APEPTrainingQuestions@azahcccs.gov.

What is the provider enrollment process?

In the most basic terms, provider enrollment (sometimes referred to as payer enrollment) is the process through which healthcare providers apply to be included in a health insurance network. As an in-network provider, you will be able to treat patients who carry that insurance and be reimbursed for your services.

How do I change my Texas Star Medicaid provider?

You can learn more by calling the Texas STAR Program Helpline at 1-800-964-2777. You can request to change your health plan at any time for any reason. If you call to change your health plan on or before the 15th of the month, the change will take place on the first day of the next month.

How do I contact Texas Medicaid provider enrollment?

For additional enrollment walkthrough assistance please contact the TMHP Contact Center (800-925-9126) or TMHP-CSHCN Services Program Contact Center (800-568-2413) or send an email to provider.relations@tmhp.com to request assistance with enrollment questions.

What is the Texas Medicaid disclosure of ownership form?

Form 5871-S is completed and submitted as a condition of approval or renewal of a Texas Medicaid enrollment application or a contract agreement between the disclosing entity (applicant/provider) and HHSC for any services program. A full and accurate disclosure of ownership and control interest is required.