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.

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

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

(3) The seven-digit medicaid legacy number and ten-digit national provider identification number for the nursing facility that is the subject of the change of owner;

(4) The extent of the owner's interest in the nursing facility;

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

(6) The manner in which the change of owner is accomplished, including through sale, merger, or other action;

(7) If the manner in which the change of owner is accomplished involves more than one step, a description of each step;

(8) The names and addresses of the persons to whom the department should send correspondence regarding the change of owner;

(9) A statement describing any material increase in lease payments or other financial obligations of the operator to the owner resulting from the change of owner, or affirming that there is no material increase;

(10) The signature of the owner's representative.