NW5 Post-Certification and Membership Agreement
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Facility Information
Please enter the date when your facility opened:
Please select your facility type:
Facility Medicare CCN/Provider #
***CCN must start with either '09', '21', '49' or '51'***
Facility National Provider Identification (NPI) #
Facility Name
Phone Number
Fax Number
Street Address 1
Street Address 2
City
State
County
Zip Code
Corporate/Parent Organization
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Examples of PHI include patient name or initials, birthdate, SSN, etc.
Next Step: Contact Information
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Contact Information
Profit Status
Location Type
Total Number of Stations
Number of Isolation Stations
***Facility Isolation Stations must be < Number of Stations***
Services Offered (check all that apply)
Name of Facility Manager/Administrator
Email Address for Facility Manager/Administrator
Name of CROWNWeb Contact
Email for CROWNWeb Contact
Next Step: Membership Agreement
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Membership Agreement
**The undersigned, on behalf of [FacilityName], hereby joins in membership with other Medicare-approved End-Stage Renal Disease (ESRD) providers in Network 5 in agreeing to participate in the activities of the Network as provided in 42 CFR § 494.180(i) of the Department of Health and Human Services’ regulations. It is understood that:
Participation in Network activities is a condition of approval to receive Medicare reimbursement for the provision of End-Stage Renal Disease services.
The dialysis facility must cooperate with the ESRD Network designated for its geographic area, Network 5, in fulfilling the terms of the Network’s current Statement of Work.
Each facility must participate in ESRD Network activities and pursue Network goals.
Failure to comply may result in sanctions by the Centers for Medicare & Medicaid Services
Name of Person Completing this Membership Agreement
Email for Person Completing this Membership Agreement:
By completing and submitting this form electronically, you acknowledge you are entering into the Network Membership Agreement electronically, as an authorized representative, on behalf of your facility.
Next Step: Submit
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