Get Application For Change Of Nursing Facility Administrator Form Texas

Filling out the Application For Change Of Nursing Facility Administrator Form is a critical step for individuals seeking to change their facility administrator in Texas. This guide provides detailed instructions to ensure a smooth online submission process.

Follow the steps to complete the application seamlessly.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editing tool.
2. In the first section, enter the facility name and its corresponding facility ID number. This information helps identify the facility for which the change is being requested.
3. Provide the effective date of the change in the specified field. This date indicates when the new administrator will officially take over.
4. Fill in the physical address of the facility, ensuring you include the street address, city, state, and ZIP code.
5. Specify the county where the facility is located.
6. Enter the facility's telephone number and FAX number in the provided fields to facilitate communication.
7. Provide the name of the new administrator. Make sure to include their first name, last name, and any relevant titles.
8. Document the facility's internet address if applicable.
9. Enter the new administrator's social security number and their license number along with the license's expiration date. Attach a current renewal card as required.
10. Fill in the permanent address of the new administrator, including street, city, state, and ZIP code.
11. If the new administrator has a different mailing address, provide that information in the next field.
12. Ensure to include the $20 application fee. Make arrangements for payment, ensuring a check or money order is made payable to the Texas Department of Aging and Disability Services.
13. In the declaration section, affirm that the information you provided is accurate and sign off as the owner/applicant or authorized representative.
14. This form requires notarization. Ensure you take the document to a notary public for their signature and seal.
15. After filling out the form, review it for accuracy, save your changes, and finalize your submission by downloading, printing, or sharing the completed document as necessary.

Begin filling out your application online today to ensure a successful transition.