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Change of Ownership (CHOW)

Medical Provider Type required *
Provider Type required *
Are you a Quality Incentive Payment Plan (QIPP) participant?
Do you intend to change ownership for a Skilled Nursing Facility (SNF)?
Have you submitted a request to obtain a new Texas Provider Identifier (TPI)? required *

Existing (To Be Termed) Business Information 

Numeric Values Only
Numeric Values Only

New Business Information 

Numeric Values Only
Numeric Values Only
Are you aware of any existing authorizations?
Are you aware of an outstanding negative balance owed by the existing business?

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.