Change of Ownership (CHOW)

Medical Provider Type *

Group Individual

Provider Type *

Primary Care Physician/Medical Behavioral Health Specialist Ancillary Nursing Facility

Effective Date of New Ownership

Are you a Quality Incentive Payment Plan (QIPP) participant?

Yes No

HHSC Contract ID

HHSC Contract Effective Date

Do you intend to change ownership for a Skilled Nursing Facility (SNF)?

Yes No

Have you submitted a request to obtain a new Texas Provider Identifier (TPI)? *

Yes No

If no, please indicate when a new TPI will be requested. *

New Business Information

Enter Provider Tax ID Number * Numeric Values Only

Provider's Billing NPI * Numeric Values Only

Medicaid Enrollment Start Date for New Entity (TPI Start Date)

Legal Business Name *

Company Name (DBA)

Mailing Address *

City *

State *

Zip Code *

Contact Name *

Contact Email Address *

Contact Phone Number *

Existing (To Be Termed) Business Information

Enter Provider Tax ID Number * Numeric Values Only

Provider's Billing NPI * Numeric Values Only

Medicaid Enrollment End Date for Existing Entity (TPI End Date)

Legal Business Name *

Company Name (DBA)

Mailing Address *

City *

State *

Zip Code *

Contact Name *

Contact Email Address *

Contact Phone Number *

Are you aware of any existing authorizations?

Yes No

If yes, please Contact Your Dedicated Account Manager.

Are you aware of an outstanding negative balance owed by the existing business?

Yes No

If yes, please Contact Your Dedicated Account Manager.

Below, please attach Superior’s Contracting and Credentialing Checklist for Individual Providers (applicable to medical and behavioral health providers) and/or Superior’s Facility and Ancillary Demographic Form (applicable to Ancillary, Long-Term Services and Supports [LTSS] and Nursing Facility providers). To download these documents, please visit Superior’s Provider Forms webpage.

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