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).
Unannounced Survey Process
When MDH has received the above documents, a request for survey will be sent to the MDH health supervisor to schedule the expansion survey.
If no deficiencies are issued at the time of the expansion survey, MDH will recommend approval for the expansion to Region V Office of CMS effective the date of the survey.
If standard level deficiencies are issued at the time of expansion survey, a plan of correction is required. With an acceptable plan of correction, MDH will recommend approval for the expansion to Region V Office of CMS effective the date the acceptable plan of correction is received in this office.
Certification Recommendation to CMS
MDH will process the expansion survey,and 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