Form 2097, Provider Contract Assignment Notification

Instructions

Updated: 5/2022

Purpose

Form 2097, Provider Contract Assignment Notification is sent to notify a person of a:

• contract termination;
• contract assignment; 
• provider change in ownership; and 
• name change in the provider’s license. 

Procedure

When to Prepare

Once the case worker is notified by their regional director of changes to a provider contract.  Case workers contact these people by phone. If unsuccessful then this form is mailed out informing the recipient of the transfer to another agency. Notify the person of the change with their contract agency. This form notifies the person of the changes with their current agency.

Transmittal

Send the completed form when a change has been communicated. The completed form should be sent once the case worker has been made aware of the change.

Detailed Instructions

The document will only allow input into certain fields (gray areas) and will not allow you to save over the original document. Move from one field (gray area) to another by pressing the "Tab" key.

Date — Enter the date the form is completed.

HHSC Contact Address and Phone No. — Enter the HHSC contact information that the person should use if they have questions.

Name and Address — Enter the recipient's name, address, city, state and ZIP code.

Program or Service — Enter the program or service with the change.

Provider Name — Enter the person's Provider Name.

Assigned Provider — Enter the Assigned Provider’s name.

Type of Change — Mark the box beside each change that applies to the person and their services.