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DEPT ID ZZ101/FUND 095 End Stage Renal Disease Facility License Renewal Addendum Name of Facility License Number 1. Services Select one Adult Only Pediatric Only Pediatric and Adult Select all that apply In-center Hemodialysis Home Hemodialysis Home Peritoneal Isolation Room Isolation Area CMS Waiver for the Isolation Room Transfer Agreement 2. Supervising Nurse c. Name of Social Worker d. Name of Dietitian 4. Medicare Certification Is the facility certified to participate in the Medicare...
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