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

CHANGE OF OWNERSHIP - CONTRACT SUPPLIER NOTIFICATION FORM - 60 Day Notice
Per Article VI of the

DMEPOS competitive bidding contract and §414.422(d)(1), a contract supplier is obligated to notify the Centers for Medicare & Medicaid Services (CMS) at

least 60 ca lendar days before the anticipated date of a change of ownership (CHOW). Failure to notify CMS may result in a breach of contraa.
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 calenda r 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 a nd the contraa supplier continues to exist and remains the supplier performing under the competitive bidding contra ct. The other
exception is a stock transfer where the business continues to exist and operate a s before the sale of stock. In these situations, the contract supplier must notify the

x

Competitive Bidding Implementation Contractor (CBIC) by mailing or fa ing all pertinent information rega rding the transaction. The seller must include all information sent to
the Nationa l Supplier Clearinghouse (NSC), a s well as any additional inf ormation necessary for assessing the impact to the sel ler's contract (e.g., any requests to add/remove
supplier locations on the contract). The contract supplier should complete the Contract Supplier Change of Location/Information Update form if necessary to add or remove
locations from the contract.
*·denotes required fields.

Anticipated Effective Date of Change

of Ownership*

IMM/DD/YYYY

Role of Contract Supplier*

v

Resulting Entity*

v

Type of Change*

v

Change of Ownership - assumes all liabilities and responsibilities of contract -

novation agreement is required.
Change in Structure - change in business struaure that results in new entity, e.g.

sole proprietor to corporation - novation agreement is required.
Stock Transfer

- contract remains the same - novation agreement may not be

required.
Is the contract supplier currently

OVes

ONo

affiliated with another contract
supplier through a previous change of
ownership?"
Does the contract supplier hold
multiple DMEPOS competitive bidding

Oves 0No

contracts?*

Seller Information
Contract Supplier*

•Yes

No

Seller's Legal BusinessName*
Doing Business AsName*

D Same as Legal Business Name
Contraa Number*

v

Authorized OfficialName*
Authorized Official's Phone*

lFile Typeapplication/pdfFile TitleConnexion - CHOW 60 DaySubjectConnexion - CHOW 60 DayAuthorPalmetto GBA/CBICFile Modified2017-02-17File Created2017-02-17