Follow the steps to complete the application online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill out Part 1, which requires the dialysis center information. Include the facility name, number, corporate affiliation, address, phone, fax, and the renal professional's contact details.
3. Complete Part 2 with patient information. Enter the social security number, date of birth, full name, mailing address, phone number, gender, and email address.
4. In Part 3, provide additional information. Specify marital status, employment status, total number of household members, race/ethnicity, kidney diagnosis, current status, treatment modality, details on vascular access, and nephrologist information.
5. Move on to Part 4 and indicate any eligibility for financial assistance. Respond to questions about Medicare and Medicaid eligibility, state renal programs, and employer flexible spending plans.
6. In Part 5, thoroughly complete household financial information. Document assets, monthly household expenses, and income to help assess eligibility.
7. In Part 6, review and confirm the patient and renal professional signature sections. Ensure the patient fully understands and agrees to the terms outlined.
8. Finally, save your changes to the form. You can download, print, or share the completed application as needed.

Complete your application online today to ensure timely assistance.