Reporting Key Staff Changes at an Ambulatory Surgical Center

Reporting Key Staff Changes at an Ambulatory Surgical Center

If you have changes in the following positions, you need to notify MDH:

  • Administrator
  • Director of Nursing
  • President Governing Board
  • Board Members
  • Managing Agent

Provide written notice on facility letterhead and include the following:

  • Health Facility Identification Number (HFID)
  • CMS Certification Number (CCN)
  • Name and address of facility
  • Change that has occurred
  • Date of change
  • Letter signed by authorized official

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

 

Updated Friday, October 10, 2014 at 03:25PM