HSS Change of Ownership Information: Hospice
Providers must complete this document when they have a change in their ownership structure. This document would be used for both a change of ownership (CHOW) as defined by state and/or federal regulations, or a change of ownership information (CHOI) that does not meet the state and/or federal regulations CHOW definition.
For Health Standards to make a CHOW/CHOI determination, all providers must submit the following documents:
- Letter of Intent (including d/b/a (doing business as) and entity name of the previous and the new owner, the effective date of change of ownership, address and phone number).
- A diagram showing the ownership structure “before” and “after” the change
- Copy of the executed legal transaction documents (Bill of Sale, lease, etc.)
- CHOW/CHOI License Application
- Change of Ownership Application
- 855A/B approval letter for the following Medicare Certified providers: Home Health, hospice, hospitals, RHCs, ASCs, ESRDs, portable x-ray, community mental health, CORF, Nursing Facilities, and OPT.
Note: If this action is a CHOI, the documents above are the only documents you need to submit, however the Department may, at its discretion, request additional documentation in support of the CHOI. If so, you will be contacted for any of said additional documents.There is no fee for a CHOI.
If this action is a CHOW, the following are also needed:
- Does your facility have a CLIA Certificate? If yes, you may also be required to complete a CHOW for CLIA.
Note: The fee for a CHOW is usually the same as a license renewal unless the facility is making additional changes. For providers completing an acquisition/merger, please contact the program desk for assistance.
Additional Documents Required:
- License Application Emergency Preparedness Addendum form (HSS Form)
- Form CMS-417 Hospice Request for Certification in the Medicare Program: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS417.pdf
- Form CMS-1561 Health Insurance Benefit Agreement (submit 3 forms each with original signatures, sign in the 3rd section as the successor if accepting provider agreement): https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS1561.pdf
- Documentation showing the seller’s or transferor’s intent to relinquish the FNR approval
- Completion of a new FNR application (HSS Form) and $200 non-refundable FNR fee
- Documentation of qualifications for administrator, director of nursing, & medical director
- Line of Credit from a federally insured, licensed lending agency for at least $75,000
- Proof of general and professional liability insurance, and worker’s compensation of at least $300,000. The certificate holder shall be the Department of Health.
- Proof of criminal background check (CBC) on the administrator and all owners. If a corporation, submit proof of CBC on all Board of Directors and principal owners.
- Articles of Incorporation/Articles of Organization
- Electronic verification from the Office of Civil Rights (OCR) of successful submission of the attestation:http://www.hhs.gov/civil-rights/for-providers/clearance-medicare-providers/index.html
- Disclosure of any financial and/or familial relationship with any other entity receiving third party payor funds, or any entity which has previously been licensed in Louisiana
- If any owners of the disclosing entity are also owners (Proprietorship, Partnership, or Board Member) of other licensed health care facilities, please submit a list of the names, addresses, and provider numbers for those facilities.
For all other Change of Ownership Information, please contact the HSS Ownership Group