Health Standards Payment Transmittal Form 2019Health Standards Section
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:
- 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.
NH CHOW Packet
For more information call: 225.342.0114
This packet is designed to assist the nursing home provider in completing and submitting the required information, forms and fees for a nursing home Change of Ownership (CHOW). Please complete all required information before submitting the packet and fees. If you have questions regarding the packet please call: 225.342.0114.
A Letter of Intent should be submitted prior to the effective date of the Change of Ownership. The letter shall plainly describe exactly what is occurring through the CHOW process(lease, purchase of assets, etc.). The letter should include; the facilities current DBA name and legal entity (corporation) name; the new owner DBA name and legal entity (corporation) name with its address and contact information; and the effective date of the transfer of ownership.
The Nursing Home license is not transferable; therefore, another licensing application and fee must be submitted. The fee of $600.00 plus $5.00 per room must be in the form of a company check, certified check, or money order payable to the Department of Health and Hospitals. If more than one CHOW occurs the fee is applicable to each.
Mail Payment & Payment Transmittal Form to:
Mail ALL other CHOW Documentation to:
DHH Licensing Payments
P.O. Box 734350Dallas, TX 75373-4350
Health Standards Section
P.O. Box 3767
Baton Rouge, LA 70821-3767
Please be sure to mail or deliver the ONLY the CHOW Documents packet NO FEES to:
LDH Health Standards Section
P.O. Box 3767
Baton Rouge, LA 70821-1811
OR, Ship To:
LDH Health Standards Section
628 N. Fourth Street, 3rd Floor
Baton Rouge, LA 70802
Documents that are provided in this packet follow:
Provider CHOW Packet Checklist – please complete and return with packet
Health Insurance Benefits agreement (CMS 1561) –– 3 copies, sign each with original signature
Documents that are not provided in this packet but may be needed to complete the CHOW follow:
1. Letter of Intent (Submitted prior to Effective date, can be seperate from CHOW Packet)
2. Signed/Dated legal documentation of Sale, Lease, or Merger, etc.
3. Resident Trust Fund Balance Information
4. A copy of the signed and dated Surety Bond agreement been included in name of the new provider.
5. A Copy of letter from Office of Management & Finance (225-342-4175) regarding outstanding fees.
6. A Copy of the COVER LETTER for the CMS 855A Medicare Enrollment App. sent to Fiscal Intermediary (FI). (or assurance that the FI has been contacted regarding the 855)
7. A copy of the facility's Hospital Transfer Agreement(s)
8. Assurance of Compliance with Civil Rights Form HHS-690
Health Standards does not have the CMS 855A Medicare Enrollment Application. The Fiscal Intermediary should be contacted regarding the CMS 855A Medicare Enrollment Application. All questions regarding the CMS 855A Medicare Enrollment Application should be directed to the fiscal intermediary or CMS.
For Information Regarding MDS Assessments:
HEALTH STANDARDS - Minimum Data Set (MDS) - Resident Assessment Instrument (RAI)
CENTERS FOR MEDICARE & MEDICAID SERVICES:FAC ID and Provider Number Change Scenarios