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:

1. 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.
2. 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
health.HRD-FedLCR@state.mn.us