Hospice Change of NameAccording to the minimum licensing regulations, notification of changes such as name and address must be provided to the department in writing or by facsimile within 24 hours of the occurrence.
A change in the name of the licensed provider requires that HSS be notified. The provider shall submit a new license application showing that the transaction being requested is a name change. A fee of $25 will be required to print a new license.
Please submit the following to complete this process:
- A “letter of intent” describing the change that has occurred and the effective date of that change
- A completed license application, (HSS Form)
- A fee of $25, (HSS Payment Procedure); and
- A copy of the articles of incorporation from the Secretary of State’s Office indicating this change.
The provider must submit notice of the change of name to the fiscal intermediary (FI) according to their process. Health Standards Section cannot complete the process until receipt of the 855A form from the FI.