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BILL OF SALE AND/OR TRANSFER OF OWNERSHIP TO
BILL OF SALE AND/OR TRANSFER OF OWNERSHIP TO A MOTOR VEHICLE. (FORM MAY BE COPIED OR FAXED, HOWEVER, ORIGINAL SIGNATURES ARE REQUIRED). For the value Received
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New York State Medicaid Enrollment Form
Has there been a change of ownership or control within the last 12 months to any of the entities (1, 2 and 3)?. □ Yes. □ No. If Yes, provide: NY Medicaid ID
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CHANGE OF OWNERSHIP FORM
New owners must file as soon as ownership is established. All change of ownership forms must include a Compliance Review Form for the new owner or operator. All.
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