Home Health

Name Change

According 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:

1. a “letter of intent” describing the change that has occurred and the effective date of that change
2. the fee of $25, (HSS Payment Procedure); and
3. 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.

Add a Branch

If you are interested in adding a branch please:

1. complete the Branch application form
2. submit non-refundable $300.00 fee (per branch)
3. Complete the CMS 855A form & submit to Fiscal Intermediary (FI)

Change of Address

According 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. 

Relocation of an Agency.  The department shall be notified in writing of any relocation of an agency.  An agency may only relocate within its geographic service area in effect on August 15, 1995, or for an agency licensed after that date, a 50-mile radius of the location where the agency was originally licensed.

Branch: an office from which a home health agency provides services within a portion of the total geographic service area served by the parent agency.  The branch office is part of the parent home health agency; is located within a 50-mile radius of the parent agency; and shares administration and supervision.

All providers having a change of address shall submit:

1. A “Letter of Intent” describing the change that has occurred and the effective date of that change.
2. A completed license application, (HSS Form)
3. A fee (HSS Payment Procedure)
   1. If the parent moves, the fee is $600 plus $300 for each branch office.
   2. If a single branch office moves, the fee is $300.
   3. If more than one branch office move, the fee is $300 per branch.

The provider must submit notice of the change of address 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.

Change of Key Personnel

A change in key personnel, such as the Administrator or Director of Nursing, requires that the provider notify HSS so that the provider's records can be updated as all communications regarding the agency will be directed to the Administrator and/or Director of Nursing. Notification shall be made using the HSS Key Personnel Change form.

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Change of Ownership 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:

1. 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).
2. A diagram showing the ownership structure “before” and “after” the change
3. Copy of the executed legal transaction documents (Bill of Sale, lease, etc.)
4. CHOW/CHOI License Application
5. Change of Ownership Application
6. 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:

1. Does your facility have a CLIA Certificate? If yes, you may also be required to complete a CHOW for CLIA. 

2. Licensing Fee: Click here for the link for the Health Standards Fee Schedule 

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:

1. License Application Emergency Preparedness Addendum form (HSS Form)
2. Form CMS-1572 Home Health Agency Survey & Deficiencies Report:  https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS1572A.pdf
3. Form CMS-1561 Health Insurance Benefit Agreement (submit 3 forms each with original signatures, sign in the 3^rd section as the successor if accepting the provider agreement): https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS1561.pdf
4. Documentation of qualifications for administrator and director of nursing
5. Line of Credit from a federally insured, licensed lending agency for at least $75,000
6. 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. 
7. 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.
8. Proof of Citizenship (on all owners & administrative personnel)
9. 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
10. Written documentation of any financial or familial relationship with any other entity providing home health care services in the state
11. 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