Closure of Facility or Voluntary Termination of an Ambulatory Surgical Center

A Medicare-certified ambulatory surgical center that closes will provide the following:

Written notice on facility letterhead that includes the following:

• Health Facility Identification Number (HFID)
• CMS Certification Number (CCN)
• Date the facility is voluntarily terminating Medicare Certification
• Specify whether the facility will or will not remain licensed
• Notice will be signed by authorized official

The Medicare-certified ambulatory surgical center will complete the Medicare Enrollment Application (CMS 855B) (PDF)

Send completed CMS-855B and all supporting documentation to your designated fiscal intermediary for approval. See Medicare Fee-for-Service Provider Enrollment Contact List (PDF).

MDH will not process the closure until after the facility notice, 855B and approval letter from the fiscal intermediary are received.

Email or mail completed documents to:

Minnesota Department of Health
Health Regulation Division
Licensing and Certification Program
PO Box 64900
St. Paul, Minnesota 55164-0900
Attn: Certification Specialist
Email address: Health.HRD-FedLCR@state.mn.us