The following state agencies must be contacted for review/approval prior to licensing:

Certificate of Need Section
Michigan Department of Community Health
Lewis Cass Building, 3rd Floor
320 South Walnut Street; Lansing, MI 48913
Telephone: (517) 241-3344

Health Facilities Engineering Section
Michigan Department of Licensing and Regulatory Affairs
PO Box 30664; Lansing, MI 48909
Telephone: (517) 241-3408

Bureau of Fire Services
Michigan Department of Licensing and Regulatory Affairs
525 W. Allegan
PO Box 30700; Lansing, MI 48909
Telephone: (517) 335-5804

State licensure fees are $238.00 annually and will be billed following the survey.

Medicare Certification Requirements
The federal Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) contracts with the Bureau of Health Systems to evaluate compliance with the federal ambulatory surgical center regulations by conducting surveys and complaint investigations. The ambulatory surgical center must be in compliance with the conditions and standards set forth in the Conditions for Coverage (42 CFR, Part 416).

Forms
The following licensure/certification forms may be sent to the Division of Licensing & Certification by either faxing it to 517-241-3354, e-mailing the attachment to dch-bhs-l&c@michigan.gov or by mailing to the Contact Information address shown below.

The Provider Enrollment application form, CMS-855, and supporting documentation should be submitted to the Fiscal Intermediary, Wisconsin Physicians Service Insurance Corporation; P.O. Box 1787, Madison, WI 53701; Phone: (608) 221-4711. Hospital based surgery centers must use the hospital Fiscal Intermediary, National Government Services, LLC.

Complete and submit the Facility Information Sheet for non-LTC Licensed Facilities (BHS-LC-101) form using one of the preceding methods during renewal time each year.

Contact Information
     Michigan Department of Licensing and Regulatory Affairs
     Bureau of Health Systems
     Division of Licensing & Certification
     PO Box 30664; Lansing, MI 48909
     Telephone: (517) 241-4160
     E-mail: dch-bhs-l&c@michigan.gov