End-Stage Renal Dialysis Facility Doing Business as (DBA) Name Change - Minnesota Dept. of Health

End-Stage Renal Dialysis Facility Doing Business as (DBA) Name Change

This page contains instructions for submitting a DBA name change of an end-stage renal dialysis facility in Minnesota.

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:
    Provide written notice on facility letterhead and include the following:
    1. Health Facility Identification Number (HFID).
    2. CMS Certification Number (CCN).
    3. Previous DBA name.
    4. New DBA name.
    5. Date of change.
    6. Notice signed by authorized official.
  3. Contact the Minnesota Secretary of State and file a Certificate of Assumed Name.

Recommendation to CMS

MDH will not process the name change until after the facility notice, Minnesota Secretary of State Certificate, 855A and approval letter from the MAC is received.

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.CM-Cert@state.mn.us

Friday, June 22, 2018 at 10:44AM