Nursing Home Dialysis Provider

New Nursing Home Contract Reporting

This form is intended for providers that deliver home dialysis to nursing home patients. Please complete each time you begin a new partnership with a nursing home. This information is required under the Network's statement of work with the Centers for Medicare & Medicaid Services and is considered participation with Network goals, which is a requirement under CMS' ESRD Network Conditions for Coverage (CfC).

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* 1. Please provide the following information about your dialysis facility:

Facility Name

CCN (your 6-digit Medicare provider number)

Name of person completing form

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* 2. Please provide the following information about the SNF/LTC facility:

Facility Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

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* 3. Select services your facility will provide:

Hemodialysis

Peritoneal Dialysis

Nursing Home Dialysis Provider

New Nursing Home Contract Reporting

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* 1. Please provide the following information about your dialysis facility:

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* 2. Please provide the following information about the SNF/LTC facility:

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* 3. Select services your facility will provide:

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* 4. What date will services begin?