End-Stage Renal Dialysis Facility Legal Entity Name Change - Minnesota Dept. of Health

End-Stage Renal Dialysis Facility Legal Entity Name Change

(Not a change of ownership)

This page contains instructions for a legal entity name change for 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. DBA name.
    4. Previous legal entity name.
    5. New legal entity name.
    6. Date of change.
    7. Notice signed by authorized official.
  3. Contact the Minnesota Secretary of State and file a Certificate of Assumed Name.
  4. Provide Certificate of Assumed Name to MDH.

Recommendation to CMS

MDH will not process the legal entity name change until after the facility notice, 855A and approval letter from the MAC is received by MDH.

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 11:06AM