New Illinois ESRD Facility - Welcome Form

Please Fill out this form to receive your Network Agreement and Welcome Packet.

FACILITY NPI (10 Digit Number)*

FACILITY NAME*

STARTUP CONTACT NAME

If the person managing facility startup is different than the on-site facility administrator, enter that contact person's name here. The on-site facility administrator will be entered further down in this form.

STARTUP CONTACT PHONE

STARTUP CONTACT EMAIL

FACILITY PHONE*

FACILITY FAX*

FACILITY ADDRESS*

FACILITY ADDRESS 2

FACILITY CITY*

FACILITY STATE*

FACILIITY ZIP*

FACILITY COUNTY*

EXPECTED CERTIFICATION DATE*

FIRST TREATMENT DATE

Enter the Date your first patient is expected to start treatment at your facility.

MEDICAL DIRECTOR NAME*

MEDICAL DIRECTOR NPI*

MEDICAL DIRECTOR EMAIL*

ONSITE ADMIN NAME*

ONSITE ADMIN EMAIL*

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