Form 3722 N PDF Details

When managing or operating nursing facilities or intermediate care facilities for individuals with intellectual disabilities or related conditions in Texas, one might encounter the need to report a change in facility administrators. This is where the Form 3722 N comes into play, serving as an essential document for ensuring that such changes are formally recognized and recorded by the Texas Department of Aging and Disability Services (DADS). This application process, outlined in the form, requires the submission of detailed information about the facility, including its name, ID number, and address, alongside personal data concerning the new administrator, such as their name, social security number, and license details. Additionally, there is a necessity for a $20 application fee alongside an affirmation that the information provided is accurate under the risk of denial, suspension, or revocation of the state license if found fraudulent. Furthermore, this document underscores the rights of individuals to request and be informed about the collected information, as well as the potential correction of any inaccuracies, highlighting DADS' commitment to transparency and lawful administration within the realm of care facilities.

QuestionAnswer
Form NameForm 3722 N
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesillinois change of administrator form, change of administrator form illinois, application for change of nursing facility administrator form texas, nursing facility change of administrator form

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Texas Dept. of Aging and Disability Services

LTC-Regulatory (E-342)

P.O. Box 149030

Austin, TX 78714-9030

(512)438-2630 FAX: (512)438-2727

APPLICATION FOR CHANGE

Nursing Facility Administrator or Administrator for Intermediate Care

Facilities for Individuals with an Intellectual Disability or Related Conditions

1.

Facility Name

 

 

 

 

 

2. Facility ID No.

 

3.

Effective Date of Change

 

 

 

 

 

 

 

 

 

 

 

4.

Physical Address (Street, City, State, ZIP)

 

 

 

 

 

 

5.

County

 

 

 

 

 

 

 

 

 

 

 

 

6.

Facility Telephone No.

 

 

7. Facility FAX No.

8. Facility Internet Address

 

 

 

 

(

)

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

Name of New Administrator

 

 

 

 

10. Social Security No.

11. Administrator License No.

 

Expiration Date

 

(Mr., Ms., Dr.) First Name

MI

Last Name

 

(Jr., Sr.)

 

 

(attach current renewal card)

 

 

 

 

 

 

New Nursing Facility Administrator’s Permanent Address (Street, City, State, Zip)

New Nursing Facility Administrator’s Mailing Address (Street, City, State, Zip)

County

County

Submit $20 Application Fee. (Make check or money order

payable to the Texas Department of Aging and Disability Services.)..................................................................................................

Fee Enclosed

$

OWNER/APPLICANT: The facts set forth in the foregoing application are true to the best of my knowledge. I understand that submission of false information in the foregoing application will constitute grounds for denial, suspension, or revocation of my state license.

Signature–Owner/Applicant (or Authorized Representative)

 

Date

Sworn to me and subscribed before me this

day of

, 20

.

Signature–Notary Public

With a few exceptions, you have the right to request and be informed about the information that the Texas Department of Aging and Disability Services (DADS) obtains about you. You are entitled to receive and review the information upon request. You also have the right to ask DADS to correct information that is determined to be incorrect (Government Code, Sections 552.021, 552.023, 559.004). To find out about your information and your right to request correction, please contact Regulatory Services Division at (512) 438-2630.

 

 

 

 

 

 

 

CHECKLIST: Nursing Home Administrator’s Current Renewal Card (nursing facilities only)

Fee ($20.00)

Notary Signature/Seal

 

 

 

 

 

 

 

 

 

 

 

 

FOR DADS USE ONLY

Application Approval Date

Reviewer

 

 

Remittance No. and Date

Form 3722-N/November 2004

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