HSS Change of Ownership Information: Adult Brain Injury Information
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. 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:
- Criminal Background Checks (new owners) compled by LSP authorized agency
- Proof of Financial Viability
- Verification of assets equal to $100,000 or the cose of 3 months operation, whichever is less; or
- Letter of credit equal to $100,000, or the cose of 3 months of operation
- General & Professional Liability Insurance at least $300,000
- Worker's Compensation Insurance
- The days and hours of operation (outpatient only)
- Articles of Incorporation/Articles of Organization
- Submission of a key personnel change form for any change in director or nursing director
Contact James H. Taylor, JamesH.Taylor@la.gov or 225-342-5457, regarding Change of Ownership Information for Hospitals.