Dialysis Facility Update Form (Services, Stations, Ownership, Address)

I have identified incorrect information in EQRS regarding the services our facility offers, stations and/or ownersip and have provided updated information below. Supporting documentation (required) is attached.

Your facility's 6-digit CCN (CMS Certification Number)
Name/Title of Person Submitting Update
Email of Person Submitting Update
Facility Update Needed (select all that apply)

Facility Update Needed (select all that apply) Facility Certified Services Facility Certified Stations Change in Ownership Facility Address Facility Hours/Shifts Dialysis Provided in Nursing Home/Long-Term Care Facility
The following CMS certified services are listed incorrectly in EQRS for this facility.
We need to ADD/REMOVE the following services. (Check all that apply):

The following CMS certified services are listed incorrectly in EQRS for this facility.
We need to ADD/REMOVE the following services. (Check all that apply): In-center Hemodialysis Services Home Hemodialysis Training and Support Services Home Peritoneal Dialysis Training and Support Services In-center Peritoneal Dialysis Services
INCENTER HEMODIALYSIS (HD): We offer the following services (Check all that apply)::

INCENTER HEMODIALYSIS (HD): We offer the following services (Check all that apply):: In-center Hemodialysis In-center Frequent Hemodialysis (5 times or more per week) In-center Nocturnal Hemodialysis REMOVE: We are not certified for In-center Hemodialysis
Effective Date of In-center Hemodialysis Services Change Effective Date of In-center Hemodialysis Services Change / MM / DD YYYY
HOME HEMODIALYSIS TRAINING AND SUPPORT: We offer the following services (Check all that apply):

HOME HEMODIALYSIS TRAINING AND SUPPORT: We offer the following services (Check all that apply): Home Hemodialysis Training Home Hemodialysis Frequent Home Hemodialysis (5 times or more per week) REMOVE: We are not certified to offer Home Hemodialysis/Training and Support
Effective Date of Home Hemodialysis Services Change Effective Date of Home Hemodialysis Services Change / MM / DD YYYY
HOME PERITONEAL (PD) TRAINING AND SUPPORT: We offer the following services (Check all that apply):

HOME PERITONEAL (PD) TRAINING AND SUPPORT: We offer the following services (Check all that apply): Peritoneal Dialysis Training Home CAPD Home CCPD Home IPD (Intermittent Peritoneal Dialysis-Rare) REMOVE: We are not certified to offer PD Training and Support
Effective Date of Home Peritoneal Dialysis (PD) Training and Support Services Change Effective Date of Home Peritoneal Dialysis (PD) Training and Support Services Change / MM / DD YYYY
IN-CENTER PERITONEAL DIALYSIS: We offer the following services:

IN-CENTER PERITONEAL DIALYSIS: We offer the following services: In-center PD - *Pt comes in-center to do PD. NOT PD Training or PD Backup. REMOVE: We are not certified to offer In-center PD
Effective Date of In-center Peritoneal Dialysis (PD) Services Change Effective Date of In-center Peritoneal Dialysis (PD) Services Change / MM / DD YYYY
Certified Stations
Isolation Stations
Total Stations Available
Effective Date for Change in Number of Stations Effective Date for Change in Number of Stations / MM / DD YYYY
Primary Ownership
Secondary Ownership
Managing Organization
Effective Date for Ownership Change Effective Date for Ownership Change / MM / DD YYYY
New Address (Street, City, Zip)
New Phone # (if applicable)
New Fax # (if applicable)
Date the State Agency was Notified of the Relocation Date the State Agency was Notified of the Relocation / MM / DD YYYY
Effective Date of Address Change Effective Date of Address Change / MM / DD YYYY
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)
Effective Date of Hours and Shifts Change Effective Date of Hours and Shifts Change / MM / DD YYYY
Onsite Nursing Home Dialysis:

Onsite Nursing Home Dialysis: We offer onsite* Home Modalities at a Nursing Home, Skilled Nursing Facility (SNF), or Long Term Care (LTC) Facility REMOVE: We no longer offer onsite* Home Modalities at a Nursing Home, Skilled Nursing Facility (SNF), or Long Term Care (LTC) Facility
*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.
Enter the name of the Nursing Home, SNF, or LTC Facility
Effective Date of Onsite Nursing Home Dialysis Change Effective Date of Onsite Nursing Home Dialysis Change / MM / DD YYYY
Attach CMS Certification Letter or NDAC or ACHC Accreditation Notice, or other documentation verifying certification or ownership updates.

Attach Files
Attach a document that contains an explanation of the change of address, hours/shifts or change in home dialysis at a nursing home. Document should be on your company's letterhead.

Attach Files
I certify that no PHI/PII was included in the attached Documentation.
(Email Address & Phone Number).