HSS Change of Ownership

Providers must complete this document when there is a change in ownership structure. This document is used for a change of ownership (CHOW) as defined by state and/or federal regulations, and/or a change of ownership information (CHOI) that does not meet the state and/or federal regulations CHOW definition.

All providers must submit the following documents to [email protected].

Documentation Required for CHOW/CHOI
  • 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.)
  • Change of Ownership Application
  • 855A/B approval letter for the following Medicare Certified providers:
    • Ambulatory Surgical Centers (ASC)
    • Community Mental Health Centers (CMHC)
    • Comprehensive Outpatient Rehab. Facilities (CORF)
    • End Stage Renal Disease (ESRD)
    • Hospitals
    • Home Health
    • Hospice
    • Nursing Facilities
    • Portable X-ray
    • Outpatient Physical Therapy (OPT)
    • Rural Health Clinics (RHC)
  • For CHOI:
    • The documents listed above are required. 
    • At its discretion, the department may request additional documentation in support of the CHOI. 
    • There is no fee for a CHOI. 
  • For CHOW: the following are also needed:
    • Does your facility have a CLIA Certificate? If yes, a CHOW for CLIA is required.
    • Fee and Payments 
      • The fee for a CHOW is usually the same as a license renewal unless additional changes are needed.
      • For providers completing an acquisition/merger, please contact the program desk for assistance.

Please select the appropriate provider type below for additional required documents.

Surgeon General Evelyn Griffin, MD

Secretary Bruce D. Greenstein

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