Form 802E Appendix B "Notice of Intent to Change Ownership" - Mississippi

What Is Form 802E Appendix B?

This is a legal form that was released by the Mississippi Department of Health - a government authority operating within Mississippi.The document is a supplement to Form 802E, Notice of Intent to Apply for a Certificate of Need. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 23, 2008;
  • The latest edition provided by the Mississippi Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 802E Appendix B by clicking the link below or browse more documents and templates provided by the Mississippi Department of Health.

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Download Form 802E Appendix B "Notice of Intent to Change Ownership" - Mississippi

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APPENDIX B
MISSISSIPPI STATE DEPARTMENT OF HEALTH
NOTICE OF INTENT TO CHANGE OWNERSHIP
(Must be accompanied by $250 processing fee)
Part I: Facility Information
Facility Name:
Address:
City:
State:
Zip Code:
County:
Telephone:
Number/Type of Licensed Beds:
Type of Organization: (County owned, non-profit, for profit, etc.)
Part II:
Purchaser/Lessee Information
Name of Organization:
Address:
City:
State:
Zip Code:
County:
Telephone:
Changes in Number/Type of Licensed Beds:
Type of Organization (non-profit, for profit, etc.
Primary Contact Person
Name:
Title or Position:
Firm:
Address:
City:
State:
Zip Code:
Telephone:
Fax:
E-mail Address:
Part III:
Seller/Lessor Information
Name of Organization:
Address:
City:
State:
Zip Code:
Owner(s):
Operator(s):
Type of Organization (non-profit, for profit, etc.
Certificate of Need Review Manual
Form No. 802 E
Effective: February 23, 2008
Health Planning and Resource Development
APPENDIX B
MISSISSIPPI STATE DEPARTMENT OF HEALTH
NOTICE OF INTENT TO CHANGE OWNERSHIP
(Must be accompanied by $250 processing fee)
Part I: Facility Information
Facility Name:
Address:
City:
State:
Zip Code:
County:
Telephone:
Number/Type of Licensed Beds:
Type of Organization: (County owned, non-profit, for profit, etc.)
Part II:
Purchaser/Lessee Information
Name of Organization:
Address:
City:
State:
Zip Code:
County:
Telephone:
Changes in Number/Type of Licensed Beds:
Type of Organization (non-profit, for profit, etc.
Primary Contact Person
Name:
Title or Position:
Firm:
Address:
City:
State:
Zip Code:
Telephone:
Fax:
E-mail Address:
Part III:
Seller/Lessor Information
Name of Organization:
Address:
City:
State:
Zip Code:
Owner(s):
Operator(s):
Type of Organization (non-profit, for profit, etc.
Certificate of Need Review Manual
Form No. 802 E
Effective: February 23, 2008
Health Planning and Resource Development
Primary Contact Person
Name:
Title or Position:
Address:
City:
State:
Zip Code:
Telephone:
Fax:
E-mail Address:
Part IV:
Type/Value of Consideration
Type Transaction:
Purchase ( )
Lease ( )
Other ( )
Describe other transaction:
Purchase/Lease Cost:
$
Fair Market Value:
$
Part V:
Expected Date of Transaction: ________________________
Part VI:
Provide the following:
(a)
The proposed (agreed upon) sales contract/lease agreement executed by the principals.
(b)
NURSING HOMES ONLY. Certification, from the Division of Medicaid, that no increase
in allowable costs to Medicaid will result from revaluation of the assets or from increased
interest and depreciation as a result of the proposed change of ownership.
Part VII:
Complete and sign the attached Certification page.
Submitted by:
_________________________________________
Name (Print or type)
_________________________________________
Title
_________________________________________
Date
_________________________________________
Address (if different than page 1)
Certificate of Need Review Manual
Form No. 802 E
Effective: February 23, 2008
Health Planning and Resource Development
.
CERTIFICATION
I (we) do solemnly swear or affirm on behalf of _________ ________________ and
________________________, after diligent research, inquiry and study, that the information and
material, contained in this foregoing Notice of Intent to Change Ownership is true, accurate, and
correct, to the best of my (our) knowledge and belief. It is understood that the Mississippi State
Department of Health and the Division of Medicaid, Office of the Governor, will rely on this
information and material in making their decision as to the exemption from Certificate of Need
Review, and if it is found that the application contains distorted facts or misrepresentation or
does not reveal truth and accuracy, the Department may require Certificate of Need review.
I (we) solemnly swear or affirm that no revision or alteration of the Notice submitted
will be made without notifying the Mississippi State Department of Health.
Signature (Purchaser)
Signature (Seller)
Title
Title
Name of Facility
Sworn to and subscribed before me, this the
day of
, 20
.
Notary Public
My Commission Expires
Certificate of Need Review Manual
Form No. 802 E
Effective: February 23, 2008
Health Planning and Resource Development
APPENDIX C
CHANGES OF OWNERSHIP OR CONTROL OF HEALTH CARE
FACILITIES UNDER MISSISSIPPI STATE BOARD OF HEALTH
LICENSURE REGULATIONS
This regulation defines what constitutes a change of ownership or control necessitating
notification of the Health Planning and Resource Development Division, Mississippi State
Department of Health, and for purposes of issuing licenses to new owners/controllers by the
Division of Licensure and Certification, Mississippi State Department of Health.
Definitions:
The following definitions shall apply to this regulation:
A.
Ownership:
1)
That person, persons or entity ultimately responsible for the control of the day-to-
day operations of the facility, as well as long-range planning and control; also
2)
That person, persons or entity legally responsible for the liabilities which accrue
by virtue of operation of a facility.
B.
Change of Ownership:
Any mechanism which transfers actual or operational control from one or more persons
or entities (owner) to another person, group of persons or entity (owner).
Examples:
1)
The following illustrate, by way of example, the principle of changes of ownership. They
are non-inclusive.
a.
Transfers of title to the business enterprise. While this may include transfers of
title to the real property constituting the facility, a transfer of title to the realty is
not necessary to establish a change of ownership.
b.
Changes in form of business enterprise, such as:
i)
Formation of corporation or partnership by a sole proprietor.
ii)
A proprietorship which elects to incorporate changes in ownership.
iii)
A sale, gift or exchange of stock which results in a 50 percent or more
change of stock ownership. For example, before a sale of stock, the
ownership of A Corporation is as follows:
Certificate of Need Review Manual
Form No. 802 E
Effective: February 23, 2008
Health Planning and Resource Development
Percent Shares
Shareholder
Owned
Mr. X
17
Mr. Y
22
Ms. Z
21
Ms. C
05
Mr. D
35
Total
100
After a stock sale, the proportion of ownership is as follows:
Percent Shares
Percentage
Shareholder
Owned
Change
Mr. X
17
0
Mr. Y
35
13
Ms. C
35
30
Mr. M
13
13
56
There has been a change of ownership of A Corp for licensure and certification
purposes, for Certificate of Need purposes.
iv)
When two or more corporations merge, with the corporation holding the
Mississippi health care facility surviving, no change of ownership has
occurred. However, if the non-surviving corporations owned defined
health care facilities, a change of ownership has occurred with respect to
those facilities.
v)
Consolidation of two or more corporations resulting in a new corporate
entity constitutes a change of ownership.
vi)
Under Mississippi law, the removal, addition, or substitution of one or
more individuals as partners dissolves the old partnership and creates a
new partnership. This constitutes a change of ownership.
vii)
Entering into a management agreement contract amounts to a change of
ownership when it conveys a large measure of control. An example would
be where the governing body of the management company or its agent has
responsibility for developing and implementing policies and procedures,
without the approval or concurrence of the former owner.
Certificate of Need Review Manual
Form No. 802 E
Effective: February 23, 2008
Health Planning and Resource Development