New ESRD Facility - Certification Notice

Please complete the following information when your facility receives its CMS Certification Letter

CMS CCN#*

State Facility Located In*

Iowa

Illinois

Kansas

Missouri

Nebraska

CMS NPI #*

FACILITY NAME*

FACILITY PHONE*

FACILITY FAX*

FIRST TREATMENT DATE*

Please provide the date your first self-pay patient was treated at your facility.

MEDICAL DIRECTOR NAME*

MEDICAL DIRECTOR NPI*

MEDICAL DIRECTOR EMAIL*

ONSITE ADMIN NAME*

ONSITE ADMIN EMAIL*

Attach a copy of your Certification Letter.

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