An exiting operator or owner of a nursing facility participating in the medicaid program shall provide the department of medicaid written notice of a facility closure or voluntary withdrawal of participation not less than ninety days before the effective date of the facility closure or voluntary withdrawal of participation. The written notice shall be provided to the department in accordance with the method specified in rules authorized by section 5165.53 of the Revised Code. The written notice shall include all of the following:

1. (A) The name of the exiting operator and, if any, the exiting operator's authorized agent;
2. (B) The name of the nursing facility that is the subject of the written notice;
3. (C) The exiting operator's medicaid provider agreement number for the nursing facility that is the subject of the written notice;
4. (D) The effective date of the facility closure or voluntary withdrawal of participation;
5. (E) The signature of the exiting operator's or owner's representative.