Form CMS-10169 Change of Ownership - Purchaser Form - 30-day notice

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*

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.

Seller (Transferor) Information
Seller's Legal Business Name*

Contract No.*
 -

Doing Business As Name*

Authorized Official Contact Telephone
NPI (if applicable)
No.*
(
)
-

Same as Legal Business Name
Authorized Official Name*

TIN*

Authorized Official E-mail Address*

Purchaser (Transferee) Information
Contract Supplier:*
Yes
Purchaser's Legal Business Name*

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

No

Contract No. (if applicable)
 -

TIN*

Authorized Official Contact Telephone
No.*
(
)
Authorized Official E-mail Address*

List all locations that will be furnishing the product category(s) for the CBA(s). Each location must meet all eligibility requirements, including the
applicable licensure and accreditation. All locations for the CBA that furnish items within the product category must be included on this list.
This information is for evaluation purposes only. If CMS determines the CHOW is acceptable, locations should be added or removed using the
Contract Supplier Location Update form on the CBIC website.
* - denotes required fields
PTAN*
CBA (Select all that apply)*

Product Category*

 Hold CTRL key and click to select multiples

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Review Pending Changes
Type

Description

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 previously
submitted and are still current. Below is the minimally required checklist. Please carefully review the CHOW fact sheet for detailed instructions.
This form
Acceptable, signed novation agreement
A 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
Documentation that confirms the Purchaser (transferee) is in compliance with all Medicare competitive bidding requirements (licensure,
accreditation, financials as applicable)
Copy of transferee's certificate and articles of incorporation (if corporation)
In accordance with the Change of Ownership requirements for the DMEPOS competitive bidding program found at 42 CFR §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.
Review & Print
Change of Ownership Form (OMB No. 0938-1016)

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

COMPETITIVE BIDDING PROGRAM