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Change of Ownership (CHOW)

New Business Information 

Numeric Values Only
Numeric Values Only

Existing (To Be Termed) Business Information 

Numeric Values Only
Numeric Values Only

Below, please attach Superior’s Contracting and Credentialing Checklist for Individual Providers (applicable to medical and behavioral health providers) and/or Superior’s Facility and Ancillary Demographic Form (applicable to Ancillary, Long-Term Services and Supports [LTSS] and Nursing Facility providers). To download these documents, please visit Superior’s Provider Forms webpage