Form CMS-10169 Change of Ownership - Contract Supplier Notificaiton For

CHANGE OF OWNERSHIP - CONTRACT SUPPLIER
NOTIFICATION FORM - 60 Day Notice
Per Article V of the DMEPOS competitive bidding contract and §414.422(d)(1), a contract supplier is obligated to notify Centers for Medicare &
Medicaid Services (CMS) at least 60 calendar days before the anticipated date of a change of ownership (CHOW). Failure to notify CMS may
result in a breach of contract.
The contracting supplier must also complete the Change of Ownership Purchaser form and submit it to the Competitive Bidding Implementation
Contractor (CBIC) along with other required documents at least 30 calendar days prior to the effective date of the CHOW. There are two
exceptions to this requirement. One is when a contract supplier is purchasing a non-contract supplier and the contract supplier continues to exist
and remains the supplier performing under the competitive bidding contract. The other exception is a stock transfer where the business continues to
exist and operate as before the sale of stock. In these situations, the contract supplier should complete the Contract Supplier Location Update form
if necessary to add or remove locations from the contract.
* - denotes required fields

Anticipated Date of Change of Ownership*

Role of Contract Supplier:*
Purchasing another contract supplier
Purchasing a non-contract supplier
Selling to another contract supplier
Selling to a non-contract supplier
Resulting Entity:*
Purchaser + Seller = Purchaser
Purchaser + Seller = Seller
Purchaser + Seller = New Entity
Type of Change:*
Change of Ownership - assumes all liabilities and responsibilities of contract - novation agreement is required.
Change in Structure - change in business structure that results in new entity, e.g. sole proprietor to corporation - novation agreement is
required.
Stock Transfer - contract remains the same - novation agreement NOT required.
Is the contract supplier currently affiliated with another contract supplier through a previous change of ownership?*
Yes No
Does the contract supplier hold multiple DMEPOS competitive bidding contracts?*

Yes

Seller Information
Contract Supplier:*
Seller's Legal Business Name*

Yes

No
Contract No. (if applicable)
 -

Doing Business As Name*
Same as Legal Business Name
Authorized Official Name*

Authorized Official Contact Telephone No.*
(
)
Authorized Official Email Address*

Purchaser Information
Information Pending:*
Contract Supplier:*

Yes No
(if yes, it is not necessary to complete the information below)
Yes No

Purchaser's Legal Business Name*

Contract No. (if applicable)

No

 -

Doing Business As Name*

Same as Legal Business Name
Authorized Official Name*

Authorized Official Contact Telephone No.*
(
)
Authorized Official Email Address*

Does the Purchaser intend to submit a novation agreement (legal documents to transfer the DMEPOS Competitive Bidding contract
from the Seller and to assume all obligations of the existing contract)?*
Yes No
Review & Print
Change of Ownership Notification Form (OMB No. 0938-1016)

Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)

COMPETITIVE BIDDING PROGRAM