Freestanding Outpatient Surgical Center
This page contains information and forms required to make application to operate as a licensed Freestanding Outpatient Surgical Center in the State of Minnesota. Additional information and forms are included to provided access to documentation required for participation as a Medicare certified Ambulatory Surgical Center. These forms are intended for use as reference. They can be downloaded and completed by individuals and organizations seeking to acquire an initial license.
Please do not use these forms to renew a current license. Currently licensed providers will receive separate notification and instructions for licensure renewal from the Department of Health. If you are unsure this is the correct license for your business or have questions, please contact the Licensing and Certification Program at 651-201-4101 or e-mail firstname.lastname@example.org to obtain additional clarification.
|Required Forms and Documents. Please read and understand all applicable documents, statutes and rules listed below before making application for this license.|
|License Application (pdf:123k/6 pages)|
|Receiving a CMS855 Form|
|Request For Certification - Medicare (pdf:8k/2 pages)|
|Health Insurance Benefits Agreement - Medicare (pdf:75k/1 page)|
|Disclosure of Ownership - Medicare (pdf:13k/3 pages)|
|Minnesota OSC Patient's Bill of Rights (pdf:21k/4 pages)|
|Related Statutes and Rules.|
|Minnesota Statutes||| 144.56 | Fees ||
|Minnesota Rules||| 4675 ||
To view the PDF files, you will need Adobe Acrobat Reader (free download from Adobe's website).