As the new owner, submit a completed Freestanding Outpatient Surgical Center license application and license fee to MDH prior to the change of ownership date. See Freestanding Outpatient Surgical Center Licensing.
The previous owner’s license fee must be paid in full.
Submit copies of legal documents signed and dated by both parties substantiating the parties involved and the effective date of the change of ownership.
Complete the following Medicare forms:
- Health Insurance Benefits Agreement (CMS-370) (PDF)
- Request to Establish Eligibility (CMS-377) (PDF)
- Medicare Enrollment Application (CMS 855B) (PDF)
- CMS-855B application and all supporting documentation will be sent to the designated fiscal intermediary for approval. See Medicare Fee-for-Service Provider Enrollment Contact List (PDF).

MDH will not proceed with the change of ownership until after we have received a copy of the CMS-855B and approval letter from the fiscal intermediary.

Email or mail 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
Email address: health.HRD-FedLCR@state.mn.us

MDH will review the documents and make a recommendation to the Region V Office of CMS. If approved, the Region V Office of CMS will send a letter to the facility.