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End-Stage Renal Dialysis Facility Request to Add Services
This page contains instructions for submitting a request to add services at an end-stage renal dialysis facility in Minnesota.
Send the following to MDH at the address below or submit via email:
- Provide written notice on facility letterhead including the name and address of facility, CMS Certification Number (CCN), Health Facility Identification number and services being added.
- Complete the ESRD Application and Survey and Certification Report (CMS-3427) (PDF).
Certification Recommendation to CMS
MDH will process the change of modality and send the federal forms with MDH recommendation to Region V Office of CMS. Region V Office of CMS will review the application and will send a letter to the facility when approved.
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