Mentor & Partner Registration

Facility Information

Please select your Network:

Please select your primary dialysis treatment facility:

My Facility is Not Listed

If you did not locate your facility above, please enter your primary treatment facility:

Contact Information

First Name:

Last Name:

Email Address:

Home Phone:

Use same number for Cell Phone

Cell Phone:

Address:

Address (Apt, Suite, etc.):

Zip Code:

City:

State:

Next Step: Interest and Experience

Interest and Experience

I would like to be a:

Select your age range:

How long have you been an ESRD/dialysis patient? * If you are a Family Partner, Family Mentor, or Facility Staff - Teammate - Advisor, how many years of experience do you have with ESRD / dialysis?

Please share your current treatment modality. *If you are a Family Partner or Family Mentor, please share the treatment modality of your patient family member.

What additional modalities do you have experience with?

Please select the language(s) you are able to speak fluently:

Other Language:

Next Step: Confidentiality / Consent Statement

I agree to act in the best interests of Quality Insights in the performance of my duties and will not allow any financial, personal, or outside professional interests to interfere with this obligation.
I will refrain from participating in any matter in which I or a family member have a financial, personal, or professional interest and will not solicit or accept gifts, gratuities, payments, or anything of value from individuals or organizations doing or seeking to do business with Quality Insights or subject to its review.
I further agree to maintain the confidentiality of all non-public, privileged, and protected health information (PHI) obtained through my participation in Patient and Family Engagement initiatives of the ESRD Networks, and to use such information solely for authorized purposes in compliance with HIPAA privacy standards.
I will not disclose PHI or the identity of any peer participant to unauthorized individuals, will safeguard all written and electronic information from public access, and will request only the minimum necessary information required to support my role.
I understand that these confidentiality obligations apply during and after my participation, and that any violation may result in dismissal from the program.

Please make a selection:

Verify you are not a robot and submit your data using the Submit button at bottom of the form

Thank you for your interest in partnering with Quality Insights End-Stage Renal Disease Networks.
Please click the SUBMIT button below to submit your interest form to the Network.
A member of our team will review your interest form and contact you with any questions or with any opportunities.