New ESRD Facility - Certification Notice
Please complete the following information when your facility receives its CMS Certification Letter
CMS NPI #
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.
Send me a copy of my responses
Your submission is being processed. Please do not close this browser window until complete.