Hospice 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. 


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 of $600 (HSS Payment Procedure)
    1. If the parent moves, the fee is $600 plus $300 for each alternative delivery site.
    2. If an alternative delivery site moves, the fee is $300.
    3. If more than one alternative delivery site move, the fee is $300 per branch.
  4. A Hospice provider undergoing a change of location within a 50 mile radius of the licensed geographic location shall submit a written attestation of the change of location and the department shall re-issue the Facility Need Review (FNR) approval with the name and new location; and

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