End-Stage Renal Dialysis Facility Change of Ownership - Minnesota Dept. of Health

Medicare Enrollment

1. Submit CMS 855A application and all supporting documentation to the designated Medicare Administrative Contractor (MAC) for approval.
   CMS 855A Medicare Enrollment Application (PDF)
   (See Medicare Fee-for-Service Provider Enrollment Contact List)
2. Send the following to MDH at the address below or submit via email:
   1. Provide written notice on facility letterhead including the name and address of facility, CMS Certification Number (CCN) number, Health Facility Identification number and change of ownership information.
   2. ESRD Application and Survey and Certification Report (CMS-3427) (PDF)
   3. Submit copies of legal documents substantiating the effective date and parties involved in the change of ownership, signed and dated by both parties.

Certification Recommendation to CMS

MDH will process all of the above documents and send to Region V Office of CMS recommending change of ownership. Region V Office of CMS will send a letter to facility acknowledging the change of ownership when approved.

Mail or email completed documents to:
Minnesota Department of Health
Health Regulation Division
Licensing and Certification Program
P.O. Box 64900
St. Paul, Minnesota 55164-0900
Attn: Certification Specialist
health.HRD-FedLCR@state.mn.us