Change of Ownership (CHOW)

Medical Provider Type *

Group Individual

Provider Type *

Primary Care Physician/Medical Behavioral Health Specialist Ancillary Nursing Facility

Do you intend to change ownership for a Skilled Nursing Facility (SNF)?

Yes No

Have you submitted a request to obtain a new Florida Medicaid ID? *

Yes No

Are you aware of any existing authorizations?

Yes No

Are you aware of an outstanding negative balance owed by the existing business?

Yes No