Change of Ownership Process for an Ambulatory Surgical Center
A Medicare-certified ambulatory surgical center that has a change of ownership will provide the following:
- As the new owner, submit a completed Freestanding Outpatient Surgical Center license application and license fee to MDH prior to the change of ownership date. See Freestanding Outpatient Surgical Center Licensing.
- The previous owner’s license fee must be paid in full.
- Submit copies of legal documents signed and dated by both parties substantiating the parties involved and the effective date of the change of ownership.
- Complete the following Medicare forms:
- Health Insurance Benefits Agreement (CMS-370) (PDF)
- Request to Establish Eligibility (CMS-377) (PDF)
- Medicare Enrollment Application (CMS 855B) (PDF)
- CMS-855B application and all supporting documentation will be sent to the designated fiscal intermediary for approval. See Medicare Fee-for-Service Provider Enrollment Contact List (PDF).
MDH will not proceed with the change of ownership until after we have received a copy of the CMS-855B and approval letter from the fiscal intermediary.
Email or mail completed documents to:
Minnesota Department of Health
Division of Compliance Monitoring
Licensing and Certification Program
P.O. Box 64900
St. Paul, Minnesota 55164-0900
Attn: Certification Specialist
Email address: health.CM-Cert@state.mn.us
MDH will review the documents and make a recommendation to the Region V Office of CMS. If approved, the Region V Office of CMS will send a letter to the facility.