Get Page 1 Of 7 August 2019 - New York State Department Of Health

Filling out the Page 1 Of 7 August 2019 form from the New York State Department Of Health is a critical step for facilities applying or notifying changes regarding End Stage Renal Disease services. This guide will provide you with a clear, step-by-step process to successfully complete the form online.

Follow the steps to accurately complete the form online.

1. Press the ‘Get Form’ button to access the form and open it in your digital workspace.
2. In the first section, indicate the type of application or notification you are submitting by checking all appropriate boxes (e.g., initial, recertification, relocation). If selecting 'Other,' specify your reason in the remarks section.
3. In the identifying information section, fill out the name of the dialysis facility, the Center for Medicare and Medicaid Services (CCN), street address, National Provider Identifier (NPI), city, county, state, and zip code.
4. Enter the fiscal year-end date, administrator’s email address, telephone number, and facsimile number.
5. Confirm if the Medicare Enrollment (CMS 855A) was completed by checking 'Yes' or 'No' as applicable.
6. Provide the name of the dialysis facility administrator, as well as their business address, state, and zip code, along with their telephone number.
7. Indicate the ownership type of the facility by selecting from 'For Profit,' 'Not for Profit,' or 'Public.'
8. Answer whether the dialysis facility is independent or part of a hospital or long-term care facility by checking the appropriate boxes.
9. Complete the sections related to the current modalities/services the facility provides and any new services being requested.
10. Fill out details regarding the number of dialysis patients and current approved in-center dialysis stations.
11. Indicate the staffing numbers for various roles, such as registered nurses and patient care technicians.
12. If applicable, provide your state license number and indicate whether a Certificate of Need is required.
13. Utilize the remarks section for any additional comments or explanations regarding your application.
14. Finally, review the completed form for accuracy, sign, and date it. You can then save your changes, download a copy, print, or share the completed form as needed.

Complete your documentation efficiently by filling out the New York State Department Of Health forms online today.