Get Esrd Form Ph 3995

Completing the Esrd Form Ph 3995 online is an important step for facilities seeking to renew their end stage renal disease program licensure. This guide offers clear, step-by-step instructions on how to effectively fill out the form with ease.

Follow the steps to successfully complete your application.

1. Click the 'Get Form' button to access the form and open it in your chosen editor.
2. Begin by filling in the name of your facility or agency, as well as the facility license number. Make sure to include the full location details such as street, city, county, state, zip code, and phone number.
3. Provide any additional contact information, including fax number and 24-hour emergency phone number, along with an email address for correspondence.
4. Enter the administrator's name and, if applicable, include a different mailing address from the facility's location.
5. In the ownership of building section, indicate the owner's name and contact information, ensuring you provide the complete address.
6. For ownership of business, check the appropriate legal entity type, indicating whether it is for profit or non-profit, and fill in the name and contact details of the legal entity.
7. List the names and addresses of all individual owners, partners, directors, or heads of the governmental entity involved.
8. Answer the accreditation questions, specifying whether the organization is accredited or deemed by a federally approved accrediting body, and provide expiration dates where necessary.
9. Indicate if the facility is chain affiliated, providing the name and contact information of the parent company if applicable.
10. If your facility is a corporation, clarify if there is a holding company, listing its details if relevant.
11. Confirm whether any owners of the disclosing entity also own other health care facilities and list those facilities if applicable.
12. State whether there is a contract with a management firm for the facility's operation and specify the contract dates and name of the firm as needed.
13. Read and verify the statement regarding compliance and responsible character, then provide your signature, title or position, and the date of signing.
14. Upon completing the form, save your changes and download it. You may also choose to print or share the form as needed.

Complete the Esrd Form Ph 3995 online today to ensure a smooth renewal process.