Licensure/Registration Index Page

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 email 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:123KB/6 pages)

MinnesotaCare Tax

Receiving a CMS855 Form

Request For Certification - Medicare (PDF: 8KB/2 pages)

Health Insurance Benefits Agreement - Medicare (PDF: 75KB/1 page)

Disclosure of Ownership - Medicare (PDF: 13KB/3 pages)

Related Statutes and Rules

Minnesota Statutes | 144.56 | Fees |
Minnesota Rules | 4675 |

Patient's Bill of Rights

Minnesota OSC Patient's Bill of Rights - Regular Print (PDF: 21KB/4 pages)

Minnesota OSC Patient's Bill of Rights - Large Print (PDF: 21KB/4 pages)

Federal Centers for Medicare and Medicaid Services

CMS - Survey & Certification - General Information

Medicare State Operations Manual (Click on Appendices Table of Contents)


Thursday, October 10, 2013 at 04:02PM