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Change of information

This page provides information and instructions for home and community support services agencies (HCSSAs) that must report changes to their:

• physical location;
• mailing address;
• telephone number;
• fax number or email address;
• operating hours;
• agency name (legal entity or doing business as);
• certification status;
• management personnel (administrator, alternate administrator, or chief financial officer);
• controlling person (stock transfers of 49 percent or less);
• category of service;
• service areas; or
• closures.

Changes must be submitted using the Home and Community Support Services Agency License Application (DADS Form 2021).

All certified agencies making any of the above changes must also submit updated information to the fiscal intermediary via the printed CMS 855A Home Health Enrollment Application (PDF format) OR the online Medicare Provider Enrollment, Chain, and Ownership System (PECOS).

Note: Effective July 16, 2012, CMS may deactivate Medicare billing privileges if a Medicare-certified HCSSA does not report a change of information supplied on the Form CMS 855A Medicare Enrollment Application within 90 calendar days of when the change occurred. Changes that must be reported by a Medicare-certified HCSSA include, but are not limited to, a change in practice location, a change in any managing employee including the supervising nurse, and a change in billing services. A change in ownership or control must be reported within 30 calendar days.

Fees

As a result of Senate Bill (SB) 223 and House Bill (HB) 1720, 82nd Texas Legislature, Regular Session, 2011, effective July 1, 2012, all HCSSAs must pay a $30 standard fee when reporting to DADS one or more of the following changes:

• change in physical location
• change in agency name (legal entity or doing business as)
• change in management personnel (administrator or chief financial officer)
• change in controlling person
• change in category of service
• change in service area

No standard fee is required if the HCSSA only reports to DADS one or more of the following changes:

• change in mailing address
• change in phone number
• change in operating hours
• change in management personnel (alternate administrator)

If a HCSSA does not submit in a timely manner the Home and Community Support Services Agency License Application (DADS Form 2021) to report one or more changes listed above, the HCSSA must pay a late fee of $100. This late fee is in addition to the $30 fee if applicable.

No fee or late fee is required if the HCSSA only reports the following changes:

• change in fax number or email address
• change in certification status
• closures

DADS accepts a certified check, money order, company check or personal check made out to the Department of Aging and Disability Services in payment for a fee.

See the chart below for a crosswalk of change types, reporting timelines and schedule of fees.

Crosswalk of change types, reporting timelines and schedule of fees

Change in HCSSA Information	Reporting Timeline (calendar days)	Standard Fee: $30	Late Fee: $100	Possible Total Fees:
Physical location (40 TAC §97.213)	At least 30 days before relocation*	Yes	Yes	$130
Mailing address, if different from physical address (40 TAC §97.214)	No later than seven days after a change	No	Yes	$100
Telephone number (40 TAC §97.214)	No later than seven days after a change	No	Yes	$100
Operating hours (40 TAC §97.214)	No later than seven days after a change	No	Yes	$100
Fax number or email address	As soon as possible	No	No	$0
HCSSA name (legal entity or doing business as) (40 TAC §97.215)	No later than seven days after the effective date of the name change	Yes	Yes	$130
Certification status (40 TAC §97.216)	No later than five days after the HCSSA decides to voluntarily withdraw from the Medicare Program	No	No	$0
Administrator, chief financial officer (40 TAC §97.218)	No later than seven days after a change	Yes	Yes	$130
Alternate administrator (40 TAC §97.218)	No later than seven days after a change	No	Yes	$100
Controlling person (40 TAC §97.218)	No later than seven days after a change	Yes	Yes	$130
Adding or deleting a category of service (40 TAC §97.219)	At least 30 days before adding At least 30 days before deleting	Yes	Yes	$130
Expanding or reducing service areas (40 TAC §97.220)	At least 30 days before expansion* At least 10 days after reduction	Yes	Yes	$130
Closure (40 TAC §97.217)	Within five days before permanent closure	No	No	$0

*unless an exemption is granted by DADS

For more information on reporting changes in application information and fees, refer to:

• Texas Administrative Code, Title 40, Part 1, Chapter 97, Subchapter C, Division 2, Rule 97.208 Reporting Changes in Application Information and Fees

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Changes in physical location or mailing address

A HCSSA must not transfer a license from one location to another without prior notice to DADS. Changes in physical address must be submitted in writing to DADS using DADS Form 2021 no later than 30 calendar days before the effective date of the change, unless DADS grants the HCSSA an exemption from the 30-day time frame as specified in 40 TAC §97.213(b).

Changes in mailing address must be submitted in writing to DADS using DADS Form 2021 no later than seven calendar days after the effective date of the change.

1. Make changes on DADS Form 2021, Home and Community Support Services Agency License Application, pages 1 and 20.
2. Place an X on page 1, number 1, on the application next to "Update: Type of Update" and write in "mailing address change" and/or "physical address change" as well as the effective date. Include the HCSSA's license number in the appropriate box.
3. On page 1, complete:
• number 3 (Name of Owner; New Address, if applicable; Tax ID Number),
• number 4 (Name of Agency), and
• number 5 (New Physical Address/Mailing Address).
4. On page 20 (Change of Information), complete, sign and date.
5. If you are required to submit a fee (standard and/or late fee), mail changes and applicable fees to Accounts Receivable in DADS state office:
   
   Regular Mail
   Regulatory Services
   Accounts Receivable
   Mail Code E-411
   Department of Aging and Disability Services
   P.O. Box 149030
   Austin, TX 78714-9030
   
   Overnight Delivery
   Regulatory Services
   Accounts Receivable
   Mail Code E-411
   Department of Aging and Disability Services
   701 West 51st St.
   Austin, TX 78751
6. If you are not required to submit a fee (standard and/or late fee), mail changes to Licensing and Credentialing in DADS state office:
   
   Regular Mail
   Regulatory Services
   Licensing and Credentialing
   Mail Code E-342
   Department of Aging and Disability Services
   P.O. Box 149030
   Austin, TX 78714-9030
   
   Overnight Delivery
   Regulatory Services
   Licensing and Credentialing
   Mail Code E-342
   Department of Aging and Disability Services
   701 West 51st St.
   Austin, TX 78751

Fees

Change in HCSSA Information	Reporting Timeline (calendar days)	Standard Fee: $30	Late Fee: $100	Possible Total Fees:
Physical address (40 TAC §97.213)	No later than 30 days before relocation*	Yes	Yes	$130
Mailing address, if different than physical address (40 TAC §97.214)	No later than seven days after a change	No	Yes	$100

*unless an exemption is granted by DADS

For more information, refer to:

• Texas Administrative Code, Title 40, Part 1, Chapter 97, Subchapter C, Division 2, Rule 97.213 Agency Relocation
• Texas Administrative Code, Title 40, Part 1, Chapter 97, Subchapter C, Division 2, Rule 97.214 Notification Procedures for a Change in Agency Contact Information and Operating Hours

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Changes in telephone number or operating hours

Changes in telephone number or operating hours must be submitted in writing to DADS using DADS Form 2021 no later than seven calendar days after the change.

1. Make changes on DADS Form 2021, Home and Community Support Services Agency License Application, pages 1 and 20.
2. Place an X on page 1, number 1, of the application next to "Update: Type of Update" and write "Change Phone or Operating Hours" as well as the effective date. Include the HCSSA's license number in the appropriate box.
3. On page 1, complete:
• number 3 (Name of Owner, Address, Tax ID Number),
• number 4 (Agency name),
• number 5 (Address), and
• number 6 (Telephone No. and/or Operating Hours).
4. On page 20 (Change of Information), complete, sign and date.
5. If you are required to submit a late fee, mail changes and applicable fee to Accounts Receivable in DADS state office:
   
   Regular Mail
   Regulatory Services
   Accounts Receivable
   Mail Code E-411
   Department of Aging and Disability Services
   P.O. Box 149030
   Austin, TX 78714-9030
   
   Overnight Delivery
   Regulatory Services
   Accounts Receivable
   Mail Code E-411
   Department of Aging and Disability Services
   701 West 51st St.
   Austin, TX 78751
6. If you are not required to submit a late fee, mail changes to Licensing and Credentialing in DADS state office:
   
   Regular Mail
   Regulatory Services
   Licensing and Credentialing
   Mail Code E-342
   Department of Aging and Disability Services
   P.O. Box 149030
   Austin, TX 78714-9030
   
   Overnight Delivery
   Regulatory Services
   Licensing and Credentialing
   Mail Code E-342
   Department of Aging and Disability Services
   701 West 51st St.
   Austin, TX 78751

Fees

Change in HCSSA Information	Reporting Timeline (calendar days)	Standard Fee: $30	Late Fee: $100	Possible Total Fees:
Telephone number and operating hours (40 TAC §97.214)	No later than seven days after a change	No	Yes	$100

For more information, refer to:

Texas Administrative Code, Title 40, Part 1, Chapter 97, Subchapter C, Division 2, Rule 97.214 Notification Procedures for a Change in Agency Contact Information and Agency Operating Hours

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Changes in fax number or email address

Changes in fax number or email should be submitted as soon as possible to ensure correct contact information is available to DADS staff.

1. Make changes on DADS Form 2021, Home and Community Support Services Agency License Application, page 1.
2. Place an X on page 1, number 1, of the application next to "Update: Type of Update" and write "Change fax number or email address" as well as the effective date. Include the HCSSA's license number in the appropriate box.
3. On page 1, complete:
• number 3 (Name of Owner, Address, Tax ID Number),
• number 4 (Agency name),
• number 5 (Address), and
• number 6 (Fax No. and/or Agency E-mail Address).
4. Mail changes to Licensing and Credentialing in DADS state office:
   
   Regular Mail
   Regulatory Services
   Licensing and Credentialing
   Mail Code E-342
   Department of Aging and Disability Services
   P.O. Box 149030
   Austin, TX 78714-9030
   
   Overnight Delivery
   Regulatory Services
   Licensing and Credentialing
   Mail Code E-342
   Department of Aging and Disability Services
   701 West 51st St.
   Austin, TX 78751

Fees

Change in HCSSA Information	Reporting Timeline	Standard Fee: $30	Late Fee: $100	Possible Total Fees:
Fax number and email address	As soon as possible	No	No	$0

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Change in HCSSA name (legal entity or doing business as)

If a HCSSA intends to change its name (legal entity or doing business as) but does not undergo a change of ownership, the HCSSA must report the name change to DADS using DADS Form 2021 no later than seven calendar days after the effective date of the name change.

1. Make changes on DADS Form 2021, Home and Community Support Services Agency License Application, pages 1 and 20.
2. Place an X on page 1, number 1, next to "Update: Type of Update" and write in "Name Change" as well as the effective date. Include the HCSSA's license number in the appropriate box.
3. On page 1, complete:
• number 3 (Name of Owner, Address, Tax ID Number),
• number 4 (New Name the Agency will be Doing Business As), and
• number 5 (Address).
4. On page 20 (Change of Information), complete, sign and date.
5. Attach a copy of the certificate of amendment from the Secretary of State (or other governmental authority).
6. Attach a copy of the assumed name certificate from the Secretary of State (or county if not filed with the Secretary of State).
7. Attach a copy of the HCSSA's current federal tax identification number. (This form comes from the federal Internal Revenue Service. IRS also refers to this number as the Employee Identification Number.)
8. Mail changes and applicable fees to Accounts Receivable in DADS state office:
   
   Regular Mail
   Regulatory Services
   Accounts Receivable
   Mail Code E-411
   Department of Aging and Disability Services
   P.O. Box 149030
   Austin, TX 78714-9030
   
   Overnight Delivery
   Regulatory Services
   Accounts Receivable
   Mail Code E-411
   Department of Aging and Disability Services
   701 West 51st St.
   Austin, TX 78751

Fees

Change in HCSSA Information	Reporting Timeline (calendar days)	Standard Fee: $30	Late Fee: $100	Possible Total Fees:
HCSSA Name Change (legal entity or doing business as) (40 TAC §97.215)	No later than seven days after the effective date of the name change	Yes	Yes	$130

For more information, refer to:

• Texas Administrative Code, Title 40, Part 1, Chapter 97, Subchapter C, Division 2, Rule 97.215 Notification Procedures for Agency Name Change

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Change in certification status

If HCSSA decides to voluntarily withdraw from the Medicare Program, the HCSSA must notify DADS in writing no later than five calendar days after the decision to withdraw is made. A HCSSA should use DADS Form 2021 to provide written notice.

1. Make changes on DADS Form 2021, Home and Community Support Services Agency License Application, page 1.
2. Place an X on page 1, number 1, on the application next to "Update: Type of Update" and write in "Certification Status Change". Include the HCSSA's license number in the appropriate box.
3. On page 1, complete:
• number 3 (Name of Owner, Address, Tax ID Number),
• number 4 (Name of Agency), and
• number 5 (Address).
4. Mail to Licensing and Credentialing in DADS state office:
   
   Regular Mail
   Regulatory Services
   Licensing and Credentialing
   Mail Code E-342
   Department of Aging and Disability Services
   P.O. Box 149030
   Austin, TX 78714-9030
   
   Overnight Delivery
   Regulatory Services
   Licensing and Credentialing
   Mail Code E-342
   Department of Aging and Disability Services
   701 West 51st St.
   Austin, TX 78751

Fees

Change in HCSSA Information	Reporting Timeline (calendar days)	Fee: $30	Late Fee: $100	Possible Total Fees:
Certification status (40 TAC §97.216)	No later than five days after the HCSSA decides to voluntarily withdraw from the Medicare Program	No	No	$0

For more information, refer to:

• Texas Administrative Code, Title 40, Part 1, Chapter 97, Subchapter C, Division 2, Rule 97.216 Change in Agency Certification Status

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Changes in management personnel (administrator, alternate administrator or chief financial officer)

Changes in administrator, alternate administrator, or chief financial officer must be submitted in writing to DADS using DADS Form 2021 no later than seven calendar days after the date of change. Changes in staff will not be made until all documentation is received.

1. Make changes on DADS Form 2021, Home and Community Support Services Agency License Application, pages 1 and 20.
2. Place an X on page 1, number 1, of the application next to "Update: Type of Update" and write in "Management Changes" as well as the effective date. Include the HCSSA's license number in the appropriate box.
3. On page 1, complete:
• number 3 (Name of Owner, Address, Tax ID Number),
• number 4 (Name the Agency will be Doing Business As),
• number 5 (Address), and
• number 6 (Management Information).
4. On page 20 (Change of Information), complete, sign and date.
5. Attach a current resume that clearly reflects:
• the qualifications for the new position according to the Texas Administrative Code, Title 40, Part 1, Chapter 97, §97.244 and §97.259;
• the month, day and year of the new position;
• all past employment history with start and termination dates;
• CEU certificates, if applicable; and
• RN license numbers, if applicable.
6. Complete and attach DADS Form 2022, Home and Community Support Services Agencies Licensure Criminal History Check
7. If you are required to submit a fee (standard and/or late fee), mail changes and applicable fees to Accounts Receivable in DADS state office:
   
   Regular Mail
   Regulatory Services
   Accounts Receivable
   Mail Code E-411
   Department of Aging and Disability Services
   P.O. Box 149030
   Austin, TX 78714-9030
   
   Overnight Delivery
   Regulatory Services
   Accounts Receivable
   Mail Code E-411
   Department of Aging and Disability Services
   701 West 51st St.
   Austin, TX 78751
8. If you are not required to submit a fee (standard and/or late fee), mail changes to Licensing and Credentialing in DADS state office:
   
   Regular Mail
   Regulatory Services
   Licensing and Credentialing
   Mail Code E-342
   Department of Aging and Disability Services
   P.O. Box 149030
   Austin, TX 78714-9030
   
   Overnight Delivery
   Regulatory Services
   Licensing and Credentialing
   Mail Code E-342
   Department of Aging and Disability Services
   701 West 51st St.
   Austin, TX 78751

Fees

Change in HCSSA Information	Reporting Timeline (calendar days)	Standard Fee: $30	Late Fee: $100	Possible Total Fees:
Administrator or chief financial officer (40 TAC §97.218)	No later than seven days after a change	Yes	Yes	$130
Alternate administrator (40 TAC §97.218)	No later than seven days after a change	No	Yes	$100

For more information, refer to:

• Texas Administrative Code, Title 40, Part 1, Chapter 97, Subchapter C Division 2 Rule 97.218 Agency Organizational Changes

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Changes in controlling person (stock transfers of 49 percent or less)

Changes in controlling person as defined in 40 TAC §97.2 must be submitted in writing to DADS using DADS Form 2021 no later than seven calendar days after the date of change. Make changes on DADS Form 2021, Home and Community Support Services Agency License Application, pages 1, 2, 5, 9 and 20.

1. Place an X on page 1, number 1, next to "Stock Transfer" and enter the effective date of the change. Include the HCSSA's license number in the appropriate box.
2. On page 1, complete:
• number 3 (Name of Owner, Address, Tax ID Number),
• number 4 (Name the Agency will be Doing Business As), and
• number 5 (Address).
3. On page 2, complete number 10a.
4. On page 5, complete number 12a, 12b and new ownership information.
5. On page 9, complete number 12b(iv) if there has been a change to the Board of Directors/Governing Body.
6. On page 20, (Change of Information), complete, sign and date.
7. Complete and attach DADS Form 2022, Home and Community Support Services Agencies Licensure Criminal History Check if applicable.
8. Attach copies of the legal and notarized documents pertaining to the stock transfer.
9. Mail changes and applicable fees to Accounts Receivable in DADS state office:
   
   Regular Mail
   Regulatory Services
   Accounts Receivable
   Mail Code E-411
   Department of Aging and Disability Services
   P.O. Box 149030
   Austin, TX 78714-9030
   
   Overnight Delivery
   Regulatory Services
   Accounts Receivable
   Mail Code E-411
   Department of Aging and Disability Services
   701 West 51st St.
   Austin, TX 78751

Fees

Change in HCSSA Information	Reporting Timeline (calendar days)	Standard Fee: $30	Late Fee: $100	Possible Total Fees:
Controlling person (40 TAC §97.218)	No later than seven days after a change	Yes	Yes	$130

For more information, refer to:

• Texas Administrative Code, Title 40, Part 1, Chapter 97, Subchapter C Division 2 Rule 97.218 Agency Organizational Changes

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Adding or deleting service categories

To add or delete a category of service to its license, a HCSSA must submit written notice to DADS using DADS Form 2021 at least 30 calendar days before the addition or deletion of the category of service.

1. Make changes on DADS Form 2021, Home and Community Support Services Agency License Application, pages 1, 2 and 20.
2. Place an X on page 1, number 1, of the application next to "Update: Type of Update" and write in "Addition of category of service" or "Deletion of category of service" and indicate which categories of service are being added or deleted as well as the effective date. Include the HCSSA's license number in the appropriate box.
3. On page 1, complete:
• number 3 (Name of Owner, Address and Tax ID Number),
• number 4 (Name the Agency will be Doing Business As), and
• number 5 (Address).
4. On page 2, complete number 9 (Category of Service); indicate which categories of services are being added or deleted.

Note: If adding Licensed and Certified Home Health (L&CHH), you must provide:

• Certificates of L&CHH from the HCSSA presurvey computer-based training for the administrator, alternate administrator, supervising nurse and alternate supervising nurse.
• Resumes for the administrator, alternate administrator, supervising nurse and alternate supervising nurse.
• Two copies of the signed Health Insurance Benefit Agreement, CMS Form 1561, each with an original signature.
• Completed Office of Civil Rights Forms.

In addition, you must complete and submit a printed Form CMS 855A Medicare Enrollment Application (PDF) OR the online Medicare Provider Enrollment, Chain, and Ownership System (PECOS) to the fiscal intermediary.

5. On page 20 (Change of Information), complete, sign, and date.
6. Mail changes and applicable fees to Accounts Receivable in DADS state office:
   
   Regular Mail
   Regulatory Services
   Accounts Receivable
   Mail Code E-411
   Department of Aging and Disability Services
   P.O. Box 149030
   Austin, TX 78714-9030
   
   Overnight Delivery
   Regulatory Services
   Accounts Receivable
   Mail Code E-411
   Department of Aging and Disability Services
   701 West 51st St.
   Austin, TX 78751

If adding a Hospice category to a current license:

1. Make changes on DADS Form 2021, Home and Community Support Services Agency License Application, pages 1, 2 and 20.
2. Place an X on page 1, number 1, next to "Update: Type of Update" and write in "Hospice Addition" as well as the effective date. Include the HCSSA's license number in the appropriate box.
3. On page 1, complete:
• number 3 (Name of Owner, Address, Tax ID Number),
• number 4 (Name the Agency will be Doing Business As), and
• number 5 (Address).
4. On page 2, complete number 9 (Category of Service); indicate Hospice Services.
5. On page 20, (Change of Information), complete, sign and date.
6. Provide certificates for Hospice from the HCSSA presurvey computer-based training for the administrator, alternate administrator, supervising nurse and alternate supervising nurse for hospice services.
7. Provide resumes for the administrator, alternate administrator, supervising nurse and alternating supervising nurse.
8. Submit two copies of the signed Health Insurance Benefit Agreement, Form CMS 1561, each with an original signature.
9. Submit two copies of the Hospice Request for Certification in Medicare, Form CMS 417, with original signatures.
10. Submit completed Office of Civil Rights Forms.
11. Mail changes and applicable fees to Accounts Receivable in DADS state office:
    
    Regular Mail
    Regulatory Services
    Accounts Receivable
    Mail Code E-411
    Department of Aging and Disability Services
    P.O. Box 149030
    Austin, TX 78714-9030
    
    Overnight Delivery
    Regulatory Services
    Accounts Receivable
    Mail Code E-411
    Department of Aging and Disability Services
    701 West 51st St.
    Austin, TX 78751

In addition, you must complete and submit a printed Form CMS 855A Medicare Enrollment Application (PDF format) OR the online Medicare Provider Enrollment, Chain, and Ownership System (PECOS) to the fiscal intermediary.

Fees

Change in HCSSA Information	Reporting Timeline (calendar days)	Standard Fee: $30	Late Fee: $100	Possible Total Fees:
Adding or deleting a category of service (40 TAC §97.219)	At least 30 days before adding At least 30 days before deleting	Yes	Yes	$130

For more information, refer to:

• Texas Administrative Code, Title 40 Part 1 Chapter 97, Subchapter C, Division 2, Rule 97.219 Procedures for Adding or Deleting A Category to the License

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Expanding or reducing service areas

A HCSSA may expand its service area at any time during the licensure period by submitting written notice to DADS using DADS Form 2021 at least 30 calendar days before the expansion.

A HCSSA may reduce its service area at any time during the licensure period by submitting written notice to DADS using DADS Form 2021 no later than 10 calendar days after the reduction.

1. Make changes on DADS Form 2021, Home and Community Support Services Agency License Application, pages 1, 3, 4 and 20.
2. Place an X on page 1, number 1, next to "Update: Type of Update" and write in "Service Area Addition" or "Service Area Deletion" as well as the effective date. Include the HCSSA's license number in the appropriate box.
3. On page 1, complete:
• number 3 (Name of Owner, Address, Tax ID Number),
• number 4 (Name the Agency will be Doing Business As), and
• number 5 (Address).
4. For changes: On pages 3 and 4, number 11, place a check mark for all current counties to be served. Note: If the HCSSA is Medicare-certified, the counties in the service area must be contiguous.
5. On page 20 (Change of Information), complete, sign and date.
6. Mail changes and applicable fees to Accounts Receivable in DADS state office:
   
   Regular Mail
   Regulatory Services
   Accounts Receivable
   Mail Code E-411
   Department of Aging and Disability Services
   P.O. Box 149030
   Austin, TX 78714-9030
   
   Overnight Delivery
   Regulatory Services
   Accounts Receivable
   Mail Code E-411
   Department of Aging and Disability Services
   701 West 51st St.
   Austin, TX 78751

Fees

Change in HCSSA Information	Reporting Timeline (calendar days)	Standard Fee: $30	Late Fee: $100	Possible Total Fees:
Expanding or reducing service areas (40 TAC §97.220)	At least 30 days before expansion* No later than 10 days after reduction	Yes	Yes	$130

*unless an exemption is granted by DADS

For more information, refer to:

• Texas Administrative Code, Title 40, Part 1, Chapter 97, Subchapter C, Division 2, Rule 97.220 Service Areas

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Closures

A HCSSA must notify DADS in writing within five calendar days before the permanent closure of the HCSSA, branch office or alternate delivery site.

1. Make changes on DADS Form 2021, Home and Community Support Services Agency License Application, page 1.
2. Place an X on page 1, number 1, of the application next to "Update: Type of Update" and write in "Closure," as well as the effective date of the closure. Include the HCSSA's license number in the appropriate box.
3. On page 1, complete:
• number 3 (Name of Owner, Address, Tax ID Number),
• number 4 (Name the Agency will be Doing Business As), and
• number 5 (Address).
4. Attach the following information: location of the client records, name and address of the client record custodian, a statement signed and dated by the owner(s) agreeing to the closure, a disposition of all active clients at the time of the closure, and the license.
5. For Medicare closure:
• Place an ad in the local newspaper 15 days before closure. Submit a copy of the ad with your closure documents to the DADS state office.
• Submit closure information to the fiscal intermediary through Form CMS 855A.
• Notify the DADS state office that the HCSSA is closing by following the steps on this page.
6. Mail or fax changes to Licensing and Credentialing in DADS state office:
   Fax: 512-438-2731
   
   Regular Mail
   Regulatory Services
   Licensing and Credentialing
   Mail Code E-342
   Department of Aging and Disability Services
   P.O. Box 149030
   Austin, TX 78714-9030
   
   Overnight Delivery
   Regulatory Services
   Licensing and Credentialing
   Mail Code E-342
   Department of Aging and Disability Services
   701 West 51st St.
   Austin, TX 78751

Fees

Change in HCSSA Information	Reporting Timeline (calendar days)	Standard Fee: $30	Late Fee: $100	Possible Total Fees:
Closure (40 TAC §97.217)	Within five days before permanent closure	No	No	$0

For more information, refer to:

• Texas Administrative Code, Title 40, Part 1, Chapter 97, Subchapter C, Division 2, Rule 97.217 Agency Closure Procedures and Voluntary Suspension of Operations

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Updated: June 4, 2013