Contact the individuals listed below to obtain the necessary Life Safety Code and Construction/Design approvals before returning the application. The Bureau of Fire Services approval is required prior to gaining a construction permit. The approval process should be coordinated with these individuals:

      Larry Horvath, Certificate of Need Section

      Michigan Department of Community Health

      Bureau of Legal and Policy Affairs

      Lewis Cass Building, 3rd Floor

      320 South Walnut Street; Lansing, MI 48933

      Telephone: (517) 241-3344

and

      Jim Scott, Health Facilities Engineering Section

      Michigan Department of Community Health

      Bureau of Health Systems; Health Facilities & Services

      PO Box 30664; Lansing, MI 48909

      Telephone: (517) 241-3408

and

      Kim Osborn, Bureau of Fire Services

      Michigan Department of Energy, Labor & Economic Growth

      300 N. Washington Square, 4^th Floor

      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 Department of Community Health, 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).

Click this link to read the priority schedule for initial Medicare surveys performed by the State.

There is no fee for certification.

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.

Click this link for information regarding a Freestanding Surgical Outpatient Facility license application addendum for pregnancy termination facilities requesting a waiver.

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 Community Health
     Bureau of Health Systems; Division of Licensing & Certification
     PO Box 30664; Lansing, MI 48909; Telephone: (517) 
     E-mail: dch-bhs-l&c@michigan.gov