Form CMS-10169 CHOW 30-day Notice (Change of Ownership Form)

CHANGE OF OWNERSHIP - PURCHASER FORM - 30 Day Notice

Purchasers of contract suppliers may request the transfer of a contract as part of a change of ownership transaction by submitting this form. The Purchaser should also
provide all required documentation outlined in the Change of Ownership (CHOW) fact sheet within 30 calendar days of the effective date of the CHOW. A fully executed
novation agreement will be required before the contract can be transferred. Please refer to the CHOW fact sheet for more detailed information and instructions.
*· denotes required fields.

Anticipated Effective Date of Change
of Ownership*

IMM/DD/YYYY

Resulting Entity*

v

Type of Change*

Change of ownership· assumes all liabilities and responsibilities of contract.

v

novation agreement is required.
Change in Structure· change in business struaure that results in new entity, e.g.
sole proprietor to corportaion . novation agreement is required.
Stock Transfer· contract remains the same. novation agreement may not be
required.

Seller (Transferor) Information
Seller's Legal Business Name*
Doing Business As Name
DSame as Legal Business Name
Contraa Number
..
TIN*
NPI (if applicable)
Authorized Official Name*
Authorized Official's Phone*
Authorized Official's Email*

Purchaser (Transferee) Information
Contract Supplier*

Ofes ONo

Purchaser's Legal Business Name*
Doing Business As Name
DSame as Legal Business Name
TIN*
Authorized Official Name*
Authorized Official's Phone*
Authorized Official's Email*

list all locations that will be furnishing the product category(s) for the CBA(s). Each location must meet all eligbi lity requirements, including the applicable licensure and
accreditation. Ali locations for the CBA that furnish items within the product category must be included on the list.
This information is for e valuation purposes only. If CMS determines the CHOW is acceptable. locations should be added or removed using the Contract Supplier Change
of Location/Information Update form in Connexion.
PTAN*
Product Category*
CBA (Select all that apply)*

v

None selected

•

Add PTAN

Cancel

Review Pending Changes
PTAN

Product Category

CBA

Action

Required Documentation
The purchaser (transferee) must submit hardcopy documents specified in §414.414(b) through (d). indicating that the new owner meets basic supplier eligibility.
accreditation. quality, and financial standards. This requirement may be omitted only if these documents were pre viously submitted and are still current. Below is the
minimally required checklist. Please carefully review the CHOW fact sheet for detailed instructions.
D Acceptable, signed novation agreement
DA cover letter or bill of sale that fully describes the nature of the transaction including parties thereto. who is buying whom. type

of purchase and resultant entity, and effective dates

D D ocumentation that confirms the Purchaser (transferee) is in compliance with all Medicare competitive bidding requirements

(licensure, accreditation. financials as applicable)

DCopy of transferee's certificate and articles of incorporation (if corporation)
In accordance with the change of ownership requirements forthe DMEPOS Competitive Bidding Program found at 42 CRF §414.422(d), I confirm the above information is
accurate and request the Competitive Bidding Implementation Contractor (CBIC) process the request to transfer the supplier contract.

The authorized official must enter his/her Connexion user ID and click Sign and Submit. You can Print a copy of the submitted form(s) for your records by clicking Print
Page.

First Name

Last Name

[
[

Phani
Atluri

Connexion User ID

Print Page

Back to Form(s) Summary

Change of Ownership Form (OMB No. 0938-1016 Exp. 9-2020)
Medicare Durable Medical Equipment, Prosthetics, Orthotics. and Supplies (DMEPOS)

Sign and Submit