In order to process a change of ownership for a Hospital and/or Ancillary Provider, 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 Proof of Liability Insurance, new W-9 and NPI letter/email (if changed) to your Network Management Consultant. Your Network Management Consultant will then contact you if additional information is needed. Please contact your Network Management Consultant if you have any questions about filling this form out.
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