Home Health Agency (HHA)- Legal Entity Name Change 

Provide Written Notice on Letterhead to include the following:

• Health Facility Identification Number (HFID)
• CMS Certification Number (CCN)
• Previous legal entity name
• New legal entity name
• Effective Date of change
• Notice will be signed by HHA official

Contact the Minnesota Secretary of State and file a Certificate of Assumed Name. See Minnesota Secretary of State: 

If deemed status, notify the accrediting organization of the legal entity name change.

Email notice to: health.HRD-FedLCR@state.mn.us

Submit CMS 855A application to the designated Medicare Administrative Contractor (MAC)

• CMS 855A Medicare Enrollment Application (PDF)
• Medicare Fee-for-Service Provider Enrollment Contact List)