Consent to Assignment of Provider Contracts (Change of Ownership-CHOW)

In order to process a change of ownership for a Hospital and/or Ancillary Provider, 2 copies of the Consent to Assignment of Provider Contracts  form must be filled out by the seller of the business and signed by both the seller and purchaser. Once completed, please fax both original signed copies along with the new Proof of Liability Insurance, new W-9 and NPI letter/email (if changed) to your Provider Contracting Representative. Your Provider Contracting Representative will then contact you if additional information is needed. Please contact your Provider Contracting Representative if you have any questions about filling this form out.