HSS Change of Ownership Information: ICF DD
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 and entity name of the previous and the new owner, the effective date of transfer of ownership, address and phone number)
- *A diagram showing the ownership structure “before” and “after” the change
- *Copy of the executed Bill of Sale
- *CHOW/CHOI License Application
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 documents are also needed:
- Does your facility have a CLIA Certificate? If yes, contact the CLIA program by clicking here.
- *Licensing Fee: Click here for the link for the Health Standards Fee Schedule
The fee for a CHOW is usually the same as a license renewal unless the facility is making additional changes. For the providers completing an acquisition/merger, please contact the program desk for assistance.
Additional Documents Required:
License Application Emergency Preparedness Addendum form
Change in Address/Location-Floor sketch/published 24 hour telephone number (if applicable)
Criminal background checks (owners) completed by a LSP authorized agency
Lease agreement (if applicable)
For all other Change of Ownership Information, please contact the HSS Ownership Group