Skip to content
SNF Dialysis Data Request
Please fill out the attached form based on facility expenses covering payments made to dialysis vendors for in home dialysis done in the SNF. HCAM appreciates any and all data available, but please be clear on the time period the data covers.
1.
Name of facility
2.
Name of person completing the form
3.
Email address
4.
Data Period in months
5.
Residents treated
6.
Total dialysis treatments completed in the data period
7.
Total dialysis vendor expenses incurred in the data period
For the next section, please complete based on what expenses your facility would have incurred if you had not done in facility dialysis
8.
Transportation expenses for dialysis residents in the data period
9.
CNA staffing expenses related to dialysis resident transport in the data period covered