HSS Change of Ownership Information: Case Management

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 and entity name of the previous and the new owner, the effective date of transfer of ownership, address and phone number)
2. *A diagram showing the ownership structure “before” and “after” the change
3. *Copy of the executed Bill of Sale
4. *CHOW/CHOI License Application

For all other Change of Ownership Information, please contact the HSS Ownership Group

Fee schedule information: click here