Form CMS-10744.Change o CMS-10744.Change o CMS-10744.Change of Ownership Form (30-day notice)

CHANGE OF OWNERSHIP - PURCHASER FORM 30 Day Notice
A Medicare-enrolled supplier that merges with or acquires a contract supplier (purchaser) may request the
transfer of a Contract as part of a change of ownership (CHOW) transaction by emailing
([email protected]) or faxing (803-264-6228) this form to the Competitive Bidding
Implementation Contractor (CBIC). The Purchaser must provide all required documentation outlined in the
Transfer a Portion of the Contract fact sheet or Transfer of Entire Contract 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 sheets on the CBIC website at
www.dmecompetitivebid.com 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 Number*

Doing Business As Name*

Auth. Official Contact Phone*

□

(

Same as Legal Business Name
Authorized Official Name*

TIN*

NPI (if applicable)

)
Authorized Official Email Address*

Purchaser (Transferee) Information
Contract Supplier*

Yes

No

Purchaser’s Legal Business Name*

Contract Number*

Doing Business As Name*

Authorized Official Contact Phone*

□

(

Same as Legal Business Name
Authorized Official Name*

)

Authorized Official Email Address*

TIN*

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 in the product category must be included on this list.
This information is for evaluation purposes only. If CMS determines the CHOW is acceptable, call the CBIC
at 877-577-5331 for direction to add or remove locations.
* - denotes required fields
PTAN*

CBA(s)*

Product Category*

Required Documentation
The purchaser (transferee) must submit hardcopy documents specified in §414.414(b) through (d),
indicating that the new owner meet all applicable competitive bidding eligibility requirements
(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. The required
documents below must also be submitted prior to the effective date of the CHOW. Please carefully review
the CHOW fact sheets for detailed instructions.
Transferring a Portion of the Contract:
• This form
• Cover letter with a description of the proposed CHOW, or a draft copy of the instrument
effectuating the CHOW (e.g., draft bill of sale);
• Contract supplier’s organizational chart/structure;
• Distinct company’s taxpayer identification number (TIN) and Provider Transaction Access Number
(PTAN(s)). To be considered distinct, a company must be operating under its own TIN;
• Distinct company’s organizational documents (e.g., certificate and articles of incorporation,
certificate of partnership, Limited Liability Corporation (LLC) formation documents); and
• Distinct company’s financial statements (i.e., income statement(s), balance sheet(s), and
statement of cash flow(s)), credit report and score and/or rating, and, the tax return extract for
the most recent year filed (if filed with the Internal Revenue Service for the distinct company’s
TIN).
Transferring the Entire Contract:
•
•
•
•

•

This form
A cover letter with a description of the proposed CHOW, or a draft copy of the instrument
effectuating the CHOW (e.g., draft bill of sale);
Purchasing entity’s tax return extract for the most recent year filed;
The following financial statements corresponding with the purchasing entity’s tax return extract
for the most recent year filed:
• Income Statement
• Balance Sheet
• Statement of Cash Flows; and
Purchasing entity’s credit report with numerical credit score or rating.

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.

Authorized Official Seller’s Name (First, Middle, Last, Jr., Sr., etc.)
PRINT

Title/Position

Signature

Authorized Official Purchaser’s Name (First, Middle, Last, Jr., Sr., etc.)
PRINT

Signature

Date

Title/Position

Date