Follow the steps to complete your application successfully.

1. Click 'Get Form' button to obtain the application and open it in your editing tool.
2. Begin by filling out the facility information. Include the doing business as (D/B/A) name, street address, and mailing address. Ensure that the D/B/A matches any advertisements and signage.
3. Provide your facility's contact details, including telephone and fax numbers.
4. Complete the ownership information section. Provide the legal name, mailing address, EIN number, and contact information. Attach the necessary IRS documentation and the ownership structure chart.
5. Answer the ownership and control interest disclosure questions. Mark ‘yes’ or ‘no’ for each inquiry, and provide details on a separate sheet if you answer ‘yes.’
6. List the key personnel involved, including the names, licensing details, and expiration dates for the Medical Director, Supervising Nurse, Social Worker, and Dietitian.
7. Detail the dialysis services offered, specifying whether they are adult only, pediatric only, or both. Indicate the method of dialysis services provided, whether in-center or home-based.
8. Specify the total number of dialysis stations and complete the required license fee based on the number of stations. Remember that fees are non-refundable.
9. Confirm the qualifications of the dialysis technicians and include any additional required documents such as fire safety surveys and life safety code attestations.
10. Have the administrator sign the application, certifying that the information is accurate and complies with regulatory requirements.
11. Finally, complete the contact person section with their details, and then save your changes, download, print, or share the completed application.

Begin your application process online today to ensure timely submission.