Legal Entity Name Change (not a change of ownership) of an Ambulatory Surgical Center

A Medicare-certified ambulatory surgical center that has a legal entity name change will provide the following:

• Health Facility Identification Number (HFID)
• CMS Certification Number (CCN)
• Doing Business AS (DBA) Name
• Previous legal entity name
• New legal entity name
• Date of change
• Notice will be signed by authorized official

Contact the Minnesota Secretary of State and file a Certificate of Assumed Name. See Secretary of State - Assumed Names/Sole Proprietorships.

Complete the Medicare Enrollment Application (CMS 855B) (PDF)

Send completed CMS-855 to your designated fiscal intermediary. See Medicare Fee-for-Service Provider Enrollment Contact List (PDF).

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

If deemed status, the Medicare-certified ambulatory surgical center will notify the accrediting organization of the name change.

MDH cannot recommend the legal entity name change until after we have received a copy of the approval letter from the accrediting organization. See CMS-Approved Accreditation Organization Contact Information (PDF).

Email or mail 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
Email address: health.CM-Cert@state.mn.us