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DEPARTMENT OF HEALTH AND HUMAN SERVICES

FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES

OMB NO. 0938-0360

END STAGE RENAL DISEASE APPLICATION AND SURVEY AND CERTIFICATION REPORT

PART 1 – APPLICATION – TO BE COMPLETED BY FACILITY

1. Type of Application/Notification (check all that apply; if “Other,” specify in “Remarks” section [Item 33]):

(V1)

1. Initial

2. Recertification

3. Relocation

4. Expansion/change of services

5. Change of ownership

6. Other, specify:

2. Name of Facility

3. CCN

4. Street Address

5. NPI

6. City

7. County

8. Fiscal Year End Date

11. Administrator’s Email Address

9. State

10. Zip Code:

12. Telephone No.

13. Facsimile No.

14. Medicare Enrollment (CMS 855A)

completed?

Yes

15. Facility Administrator Name:

Address:

City:

State:

Zip Code:

Telephone No:

16. Ownership

1. For Profit

2. Not for Profit

3. Public

(V2)

17. Is this facility owned and managed by a hospital and on the hospital campus (i.e., hospital-based)?

1. Yes

2. No

(V3)

Is this facility owned and managed by a hospital and located off the hospital campus (i.e., satellite)?

1. Yes

2. No

(V4)

Is this facility not owned or managed by a hospital (i.e., independent)?

1. Yes

2. No

(V5)

If owned and managed by a hospital: hospital name:

CCN:

(V6)

(V7)

18. Is this facility located in a SNF/NF (check one):

1. Yes

2. No

(V8)

If Yes, SNF/NF name:

CCN:

(V9)

(V10)

19. Is this facility owned &/or managed by a multi-facility organization?

1. No

2. Yes, Owned

3. Yes, Managed

(V11)

If Yes, name of multi-facility organization:

(V12)

Multi-facility organization’s address:

20. Current Services (check all that apply):

(V13)

1. In-center Hemodialysis (HD)

2. In-center Peritoneal Dialysis (PD)

3. In-center Nocturnal HD

4. Reuse

5. Home HD Training & Support

6. Home PD Training & Support

7. Home Training & Support only

21. New services being requested (check all that apply):

(V14)

1. N/A

2. In-center HD

3. In-center PD

4. In-center Nocturnal HD

5. Reuse

6. Home HD Training & Support

7. Home PD Training & Support

8. Home Training & Support only

22. Does the facility have any home dialysis (PD/HD) patients receiving dialysis in long-term care (LTC) facilities?

1. Yes

2. No

(V15)

LTC (SNF/NF) facility name:

CCN:

(V16)

(V17)

Staffing for home dialysis in LTC provided by:

1. This dialysis facility

2. LTC staff

3. Other, specify

(V18)

Type of home dialysis provided in this LTC facility:

1. HD

2. PD

(V19)

For additional LTC facilities, record this information and attach to the “Remarks” (item 33) section.

23. Number of dialysis patients currently on census:

In-Center HD:

____

In-Center Nocturnal HD:

____

In-Center PD:

____

(V20)

(V21)

(V22)

Home PD:

____

Home HD <= 3x/week:

____

Home HD >3x/week:

____

(V23)

(V24)

(V25)

24. Number of approved in-center dialysis stations:

___

Onsite home training room(s) provided?

1. Yes

2. N/A

(V26)

(V27)

25. Additional stations being requested:

None

In-center HD:

_____ In-center nocturnal HD:

_____

(V28)

(V29)

(V30)

In-center PD:

_____

(V31)

FORM CMS-3427 (Revision 05/13)

Form Cms-3427 - End Stage Renal Disease Application And Survey And Certification Report

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