Ohio Revised Code Title LI. Public Welfare § 5165.51

(1) The name of the exiting operator and, if any, the exiting operator's authorized agent;

(2) The name of the nursing facility that is the subject of the change of operator;

(3) The exiting operator's seven-digit medicaid legacy number and ten-digit national provider identifier number for the nursing facility that is the subject of the change of operator;

(4) The name of the entering operator;

(5) The effective date of the change of operator;

(6) The manner in which the entering operator becomes the nursing facility's operator, including through sale, lease, merger, or other action;

(7) If the manner in which the entering operator becomes the nursing facility's operator involves more than one step, a description of each step;

(8) Written authorization from the exiting operator or owner and entering operator for the department to process a provider agreement for the entering operator;

(9) The names and addresses of the persons to whom the department should send initial correspondence regarding the change of operator;

(10) If the nursing facility also participates in the medicare program, notification of whether the entering operator intends to accept assignment of the exiting operator's medicare provider agreement;

(11) The signature of the exiting operator's or owner's representative.