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 # | Description | Check List |
HS 328 | Notice – Effective Date of Provider Agreement - If applying for both Medi-Cal & Medicare certification, only need one copy of this form.
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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.
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| 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.
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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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