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EDMUND G. BROWN JR.
Governor

State of California—Health and Human Services Agency
California Department of Public Health



​Chronic Dialysis Clinic: End-stage Renal Disease - Medicare Certification
Applicant Checklist

The following forms and information are required for Medicare certification. Medicare certification only applies to End-Stage Renal Disease facilities.
Note: All forms listed are in PDF format. 

Form #​DescriptionCheck List

​HS 328

​Notice – Effective Date of Provider Agreement
  • If applying for both Medi-Cal & Medicare certification, only need one copy of this form.

CMS 855A

​Medicare General Enrollment Health Care Provider/Supplier Application
  • This application is from the Federal Department of Health and Human Services.
  • The completed application should be mailed directly to the appropriate fiscal intermediary.
CMS 3427

​End-Stage Renal Disease Application/Notification and Survey and Certification Report

  • The applicant will need to complete and provide all information that they have on Sections 1 thru 24 (except #2).
  • Note: The surveyor will bring a copy of this form to the facility to update and add additional information, when the certification survey is conducted.

Business Plan Letter 

Business Plan Letter

  • Submit a business plan letter explaining (with detailed information) your "Business Plan" for operation of the ESRD, including a description of all services to be provided.

 



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