Change of Ownership of a Nursing Home

Licensure Procedure

In order to apply for a change of ownership (CHOW) with the Division of Health Service Regulation, you must do the following:

  1. Complete these licensure forms.
    1. Nursing Home Application - Change of Ownership (PDF, 63 KB)
    2. Breakdown of Room Numbers and Beds Within Those Rooms, DHSR-4504 (PDF, 21 KB)
    3. Alzheimer's Special Care Unit Required Disclosures Data Supplement (PDF, 20 KB), if applicable.
  2. Include a nonrefundable annual license fee of $420.00 plus a per-bed fee of $17.50 (G.S. 131E-102(b). Payment should be in the form of a check, money order or certified check to "The Division of Health Service Regulation." Payment should include the facility's license number. A separate check is required for each licensed entity. The license fee must accompany the license application prior to the issuance of the nursing home license. The legislation (SB 622, Session Law 2005-276) prohibits DHSR from issuing a license if the provider has not paid the fee.
  3. Include a signed copy of the final lease agreement or bill of sale.
  4. Include a written statement from the current licensee surrendering the license.

    Submit the above information to: Qwony Jones
    DHHS - DHSR, Nursing Home Licensure and Certification Section
    2711 Mail Service Center
    Raleigh, NC 27699-2711

  5. Notify the Certificate of Need Section (CON) if you are acquiring the real property (i.e. bricks and mortar). The CON Section phone number is 919-855-3873.

DHSR will issue a new license for the CHOW once the current licensee has vacated the premises and surrendered the license, in writing.

Medicare Enrollment Procedure

  1. Complete these forms.
    1. Medicare Provider Enrollment Application, CMS-855A (PDF, 1.04 MB). You can direct any questions regarding the completion of this form to your Medicare Administrative Contractor (MAC) (PDF, 205 KB). Providers may no longer express a preference for a particular MAC or request a change of MAC. If the new owner, following a CHOW, accepts assignment of the existing provider agreement, it will continue with the same MAC as the previous owner. If the new owner does not accept assignment of the existing provider agreement, the Center for Medicare & Medicaid Services (CMS) will consider the new owner as a new enrollee for certification. It must complete the initial application process, have the state agency perform an initial certification survey, and receive certification approval from the CMS regional office. CMS issues the provider a new CMS Certification Number (CCN) and assigns the provider to the local designated MAC. New providers that belong to CMS-recognized chains have the option of being assigned to the local designed MAC or to the MAC that serves the chain home office. More information about the MAC can be found here Medicare Administrative Contractor (PDF, 28 KB).
    2. Submit an attestation of compliance with all applicable civil rights laws enforced by Office of Civil Rights (OCR) electronically via OCR's online Assurance of Compliance portal. Enclose a copy of evidence of successful electronic submission (e-mail) to the Nursing Home Section.
    3. Long Term Care Facility Application for Medicare and Medicaid, CMS-671 (PDF, 367 KB)
    4. Health Insurance Benefits Agreement, CMS-1561 (PDF, 415 KB),
      • If it is your intent to assume the previous owner's Medicare provider agreement, complete the "successor provider of services" signature line.
      • If you desire issuance of a new provider agreement (necessitates onsite survey to determine compliance), complete the "provider of services" signature line. A new owner may refuse to accept assignment of the previous owner's provider agreement. This means the provider agreement terminated effective with the CHOW date. The new owner should put the refusal in writing and forward to Becky Wertz, 60 days prior to the CHOW date to allow for the orderly transfer of any beneficiaries of the provider.

Submit the required information to: Qwony Jones
DHHS - DHSR, Nursing Home Licensure and Certification Section
2711 Mail Service Center
Raleigh, NC 27699-2711

Contact or for further assistance.