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End-Stage Renal Dialysis Facility Closure
This page contains instructions for submitting a closure of an end-stage renal dialysis facility in Minnesota.
- Submit CMS 855A application and all supporting documentation to the designated Medicare Administrative Contractor (MAC) for approval.
CMS 855A Medicare Enrollment Application (PDF)
(See Medicare Fee-for-Service Provider Enrollment Contact List)
- Send written notice to MDH at the address below or submit via email prior to closure.
The written notice shall include the following:
- Health Facility Identification Number (HFID).
- CMS Certification Number (CCN).
- Date the facility closed.
- Notice signed by authorized official.
Certification Recommendation to CMS
MDH will not inform CMS of the closure until after the closure notice from the facility, CMS 855A and approval letter from the MAC is received by MDH.
Mail or email to:
Minnesota Department of Health
Health Regulation Division
Licensing and Certification Program
P.O. Box 64900
St. Paul, Minnesota 55164-0900
Attn: Certification Specialist