New Facility Agreement Application

Facility Legal Name

Network

New Facility-never certified by CMS

If certified, complete this question

Facility DBA Name

DBA = Doing Business As.

Facility NPI Number

Not the NPI for the Medical Director or other physician. All facilities MUST have an organizational NPI.

Facility Phone Number

Facility Fax Number

Facility Email Address

Website

Physical Address Line 1

Physical Address Line 2

City

Physical State

Zip Code + 4 digit extension

County

Mailing Address (if different from Physical)

Mailing Address Line 2

Mailing Address City

Mailing State

Mailing Address Zip Code + 4 digit extension

Approximate Open Date

If unknown, give best estimate or target date.

Profit Status

Batching Organization

Owned By (Ex. DaVita, FMC, USRC)

Other Owner

Manged by

Applicable only to non-LDO facilities which are managed by LDO under arrangement. Otherwise, this is N/A.

Program Type

Location Type

Number of Stations

Number of Isolations Stations

Total Number of Stations

Services Offered (Check all that apply)

Days open

Number of shifts M-W-F

Number of Shifts T-Th-Sat

Facility staff

Please include credentials for ALL staff (MD, RN, MSW, RD, etc.)

Medical Directors NPI

Medical Director Name

Physician credentials

MD Phone number

MD email address

Facility Administrator/Clinic Manager Name

Facility manager credentials

FA/CM Phone Number

FA/CM email address

Social Worker Name

Social worker credentials

SW Phone Number

SW email address

Dietitian Name

Dietitian credentials

Dietitian Phone Number

Dietitian emal address

Data Contact Name

Data Contact Phone Number

Data Contact email address

Disaster Coordinator (DC) Name

DC Phone Number

Non-facility Phone Number

DC email address

Back-up Disaster Coordinator (BDC) Name

BDC Phone Number

Non-facility Phone Number

BDC email address

Agreement Form

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