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 W-9 and NPI letter/email (if changed) to your local Provider Representative. Your local Provider Representative will then contact you if additional information is needed. Please contact your provider representative if you have any questions about filling this form out.

updated 4/2008