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 Provides onsite* Home Modalities at a Nursing Home or LTC Facility N/A - None apply
*Onsite means your nursing staff will travel to the nursing home or long term care facility and provide dialysis to the patient. It does not include patients who treat independently in their care facility without staff assistance.
FACILITY STATIONS
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

FACILITY STATIONS

OWNERSHIP

HOURS AND SHIFTS