Reporting Key Staff Changes at an Ambulatory Surgical Center

If you have changes in the following positions, you need to notify MDH:

• Administrator
• Director of Nursing
• President Governing Board
• Board Members
• Managing Agent

Provide written notice on facility letterhead and include the following:

• Health Facility Identification Number (HFID)
• CMS Certification Number (CCN)
• Name and address of facility
• Change that has occurred
• Date of change
• Letter signed by authorized official

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.HRD-FedLCR@state.mn.us