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