Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 14
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54SECTION 2: IDENTIFYING INFORMATION
(Continued)
F. Change of Ownership (CHOW) Information
Both the seller/former owner and the new owner should complete this section. (As the new owner may
not know all of the seller/former owner’s data, it should furnish this information on an “if known” basis.)
The seller/former owner must complete Sections 1A, 2F, 13, and either 15 or 16. (Section 6 must also be
completed if the signer has never completed Section 6 before.) The new owner must complete the
entire application.
Legal Business Name of “Seller/Former Owner” as reported to the Internal Revenue Service
“Doing Business As” Name of Seller/Former Owner (if applicable) Old Owner’s Medicare Identification Number (if issued)
Old Owner’s NPI
Effective Date of Transfer (this can
Name of Fee-For-Service Contractor of
be a future date) (mm/dd/yyyy)
Seller/Former Owner
Will the new owner be accepting assignment of the current “Provider Agreement?”
YES
NO
If the answer is “No,” then this is an initial enrollment and the new owner should follow the instructions
for “New Enrollees” in Section 1 of this form.
Submit one copy of the bill of sale with the application. A copy of the final sales agreement must be
submitted once the sale is executed.
G. Acquisitions/Mergers
Effective Date of Acquisition (mm/dd/yyyy)
The seller/former owner need only complete Sections 1A, 2G, 13, and either 15 or 16; the new owner
must complete Sections 1A, 2G, 4, 13, and either 15 or 16. (Section 6 must also be completed if the signer
has never completed Section 6 before.)
1. PROVIDER BEING ACQUIRED
This section is to be completed with information about the currently enrolled provider that is being
acquired and will no longer retain its current Medicare provider number as a result of this acquisition.
Legal Business Name of the “Provider Being Acquired” as reported to the Internal Revenue Service
Current Fee-for-Service Contractor
Provide the name and Medicare identification number of all units of the above provider that have separate
Medicare identification numbers but have not entered into separate provider agreements, such as swing bed
units of a hospital and HHA branches. Also furnish the NPI. Units that already have a separate provider
agreement should not be reported here.
MEDICARE IDENTIFICATION
NAME/DEPARTMENT
NATIONAL PROVIDER IDENTIFIER
NUMBER (IF ISSUED)
CMS-855A (07/11)
13
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