End-Stage Renal Disease (ESRD) Data Collection Form

The Medical Facilities Planning Branch's June 2013 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, November 1, 2013.

  1. Complete and sign the form.
  2. Rename the workbook to include the facility's Medicare provider number in the filename.
  3. Email the Excel workbook to DHSR.SMFP.ESRD-Inventory@dhhs.nc.gov.

Form

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