Notification of Change of Ownership (CHOW)

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A Notification of Change of Ownership form (CHOW) is required when participating healthcare providers are involved in a practice transfer to a new owner. The CHOW collects detailed information from both the Purchaser and Seller. Neighborhood Health Plan of Rhode Island will review the CHOW information prior to the processing of any contractual changes.
Date*
MM slash DD slash YYYY
Legal name of Seller/Assignee:*
Name of Entity:*
NPI II Number:*
Legal name of Purchaser/Assignee:*
Name of Entity after transfer:*
New Operating NPI II Number:*
Provider group and its practitioners are enrolled with Rhode Island Medicaid
Provider group and its practitioners are enrolled with Rhode Island Medicaid
- Yes
- No
Per federal requirements, all providers participating in the Neighborhood network are required to be enrolled with Rhode Island Medicaid. If you are currently not enrolled with Rhode Island Medicaid, please visit the Rhode Island Executive Office of Health and Human Services Provider Enrollment Page for additional information on how to enroll: Rhode Island Medicaid Provider Enrollment Application.
Contact Name:*
Contact e-mail address:*
Contact telephone:*
Purchaser must submit a CHOW. Click here and save this form to your desktop, complete the CHOW (with signatures from Purchaser and Seller), and attach/upload the document to this form.
Notification of Change of Ownership Form*
Accepted file types: doc, docx, xls, xlsx, pdf, Max. file size: 10 MB.
CHOW Submission Date*
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