Form CMS-10169 Change of Ownership (CHOW) Purchaser Form

CHANGE OF OWNERSHIP- PURCHASER FORM
Purchasers of contr act suppliers may r equest the transfer of a contr act as part of a change of ownership transaction. A Purchaser should provide all
information on this form and the required documentation outlined in the Change of Ownership (CHOW) fact sheet at least 30 calendar days before the
effective date of the CHOW. Please refer to the CHOW fact sheet for more detailed information and instructions.

* - denotes r equir ed fields
Anticipated Effective Date of Change of Ownership'"

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Resulting Entity:*

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Successor Entity ( Company A

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New Entity (Company A + Company 6

+ Company

6 = Company A)

= Company

C)

Type of Purchase:*

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Asset - purchase of assets without assuming liabilities

C

Asset and liabilities - purchase of assets and assuming the liabilities of the seller

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Stock only - purchase of corporate stock ( as in shar es possessed by a stockholder)
A sale of corpor at e stock ( as in shar es possessed by a s tock holder) does not constitute a change of ow ner ship. This form is for r eporting changes of
own-ership that r equir e the submission o f a novation agr eement for Ct>~IS appr oval. Please use the Change. of Location and t he Change of Information
forms to up-dat e your informat ion.

Seller (Transferor) Information
Seller·s legal Business Name*

Contract No. *

NPI (if applicable)

1:8 - .-------

TIN*

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Doing Business As Name *

Authorized Official Contact Telephone No.*

Ir

Charlotte-Gastonia-Concord, NC-SC
Cincinnati-Middletown, OH-KY-IN
Cleveland-Elyria-Mentor, OH
Dallas-Fort-Worth-Arlington, lX
Kansas City, MO-KS
Miami-Fourt Lauderdale-Pompano Beach, FL

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( Add PTAN ) ( 8ancel )

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IDescription

[ Type

IAction

Required Documentation
The pur chaser (transfer ee) must submit hardcopy documents specified in §4 14.414(b) through ( d), indicating that the new owner meets basic supplier
eligibility, accr editation, quality, and financial standards. This r equir ement may be omitted only if these documents wer e previously submitted and ar e
still current. Below is the minimally r equir ed checklist. Please carefully r eview the CHOW fact sheet for detailed instructions.

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This form

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Acceptable, signed novation agr eement

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Document describing natur e of the CHOW transaction

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Documentation that confirms the Purchaser (transfer ee) is in compliance with all f'tledicare competitive bidding r equir ements

(licensure, accr editation, financials as applicable)
~ Copy of transferee's certificate and articles of incorpor ation (if corporation)

In accor dance with the Change of Ownership r equirements for the Df'i1EPOS c ompetitive bidding program found at 42 CFR §4 14.422(d), I confirm the
above information is accur ate and r equest the Competitive Bidding Implementation Contr actor ( CBIC) process the r equest to transfer the supplier
contract.

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