New Facility Agreement Application

New Facility Agreement Application

Facility Legal Name*

Network*

Select or enter value

New Facility-never certified by CMS*

Select or enter value

If certified, complete this question

Select or enter value

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*

Select or enter value

Zip Code + 4 digit extension*

County*

Mailing Address (if different from Physical)

Mailing Address Line 2

Mailing Address City

Mailing State

Select or enter value

Mailing Address Zip Code + 4 digit extension

Approximate Open Date*

If unknown, give best estimate or target date.

Profit Status*

Select or enter value

Batching Organization*

Select or enter value

Owned By (Ex. DaVita, FMC, USRC)*

Other Owner

Manged by*

Program Type*

Select or enter value

Location Type*

Select or enter value

Number of Stations*

Number of Isolations Stations*

Total Number of Stations*

Services Offered (Check all that apply)*

Select or enter value

Days open*

Select or enter value

Number of shifts M-W-F*

Number of Shifts T-Th-Sat*

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

Medical Directors NPI*

Medical Director (MD) Name*

MD Phone number*

MD email address*

Facility Administrator/Clinic Manager (FA/CM) Name*

FA/CM Phone Number*

FA/CM email address*

Social Worker (SW) Name*

SW Phone Number*

SW email address*

Dietitian Name*

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 and Handbook Acknowledgement Forms.

Upload your COMPLETED agreement and handbook acknowledgement Form here.

You can also fax the documents to Debbie at 972-503-3219 or email to debbie.odaniel@allianthealth.org. Forms can be located on the Network website under Providers, New Facility Requirements.

Drag and drop files here or

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

Agreement and Handbook Acknowledgement Forms.

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