End-Stage Renal Disease (ESRD) Data Collection Form

The Medical Facilities Planning Branch's December 2014 data collection form for ESRD facilities is now available for download. This information is needed to report current utilization of in-center dialysis stations services and determine the percentage of patients receiving home dialysis in the state to project future need for new dialysis stations and facilities. Documented need for such service is a requirement in order to expand the number of facilities or stations for any county in the state.

Please download the form, complete all sections and return to the Medical Facilities Planning Branch by Friday, February 27, 2015.

  1. Complete and sign the form.
  2. The workbook must be renamed using the capital letters ESRD followed by the facility's Medicare provider number with no dash or space in between the letters and numbers in the filename.(e.g. ESRD342815)
  3. Email the Excel workbook to DHSR.SMFP.ESRD-Inventory@dhhs.nc.gov.

Form

If you have questions, call Tom Dickson in the Medical Facilities Planning Branch at 919-855-3865 or email DHSR.SMFP.ESRD-Inventory@dhhs.nc.gov.