New Facility Information Form

INSTRUCTIONS

Please use this form if you are a new dialysis facility/provider. Complete all known fields and submit the completed form to the Network
FACILITY CONTACT INFORMATION
Primary Contact Name/Title *
Primary Contact Phone Primary Contact Phone * - ### - ### ####
Primary Contact Email *
Facility/Provider Legal Name *
Facility/Provider Doing Business As (DBA) Name (if different from Legal Name)
Physical Address of Facility
Street Address Line 1 (Physical) *
City/State/Zip (Physical) *
County (Physical) *
Mailing Address

Mailing Address Same as Physical Address
Street Address Line 1 (Mailing)
City/State/Zip (Mailing)
County (Mailing)
Facility Phone # Facility Phone # * - ### - ### ####
Facility Fax # Facility Fax # - ### - ### ####
FACILITY CERTIFICATION INFORMATION
Provider Use Type *

Provider Use Type Pending Certification Medicare VA
Program Type *

Program Type Dialysis Transplant
Facility CMS Certification Number (CCN)
If not certified, enter "Pending"
Facility NPI# *
Facility Details
Location Type *

Location Type Renal Dialysis Facility Hospital Based Renal Dialysis Facility Hospital Based Satellite Dialysis Facility Special Purpose Facility Hospital Based Special Purpose Facility
Facility Status: Open *

Facility Status: Open Yes No
Facility Date Opened Facility Date Opened / MM / DD YYYY
Approximate Open Date Approximate Open Date / MM / DD YYYY
FACILITY SERVICES INFORMATION
Hemodialysis Services (Check all that apply) *

Hemodialysis Services (Check all that apply) In-center Hemodialysis Home Training and Support (HHD) Frequent In-center Hemodialysis Frequent Home Hemodialysis In-center Nocturnal Hemodialysis N/A - Do not offer hemodialysis
Peritoneal Dialysis (PD) Services (Check all that apply) *

Peritoneal Dialysis (PD) Services (Check all that apply) PD Home Training and Support In-center Peritoneal Dialysis (NOT PD Training or backup) N/A - Do not offer Peritoneal Dialysis
In-center Peritoneal Dialysis (PD) Services *

In-center Peritoneal Dialysis (PD) Services In-center CCPD In-center CAPD In-center IPD
Home Peritoneal Dialysis (PD) Services *

Home Peritoneal Dialysis (PD) Services Home CCPD Home CAPD Home IPD (Intermittent Peritoneal Dialysis)
Additional Services Offered (Check all that apply) *

Additional Services Offered (Check all that apply) Accepts Pediatrics Isolation Stations Accepts Transients Practices Dialyzer Reuse Shift starts after 5pm N/A - None apply
Certified Stations *
Isolation Stations *
Total Stations Available
OWNERSHIP
Profit Status *

Profit Status Profit Non-Profit
Primary Ownership *
Secondary Ownership
Managing Organization
HOURS AND SHIFTS
Days Open *

Days Open Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Enter COMPLETE Hours and Shifts Description (Day / Time Start / Time End / Number of Shifts) *
Date Submitted Date Submitted / MM / DD YYYY

New Facility Information Form

New Facility Information Form

INSTRUCTIONS

FACILITY CONTACT INFORMATION

Physical Address of Facility

FACILITY CERTIFICATION INFORMATION

Facility Details

FACILITY SERVICES INFORMATION

OWNERSHIP

HOURS AND SHIFTS