Get the free Renal Facility 265-2011 form - Centers for Medicare ... - CMS.gov
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FOR BHF USELL1
2015
STATE OF ILLINOIS
DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
FINANCIAL AND STATISTICAL REPORT (COST REPORT)
FOR LONGER CARE FACILITIES
(FISCAL YEAR 2015)I.DPH License ID Number:
Facility
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How to fill out renal facility 265-2011 form
How to fill out renal facility 265-2011 form
01
To fill out the renal facility 265-2011 form, follow these steps:
02
Start by entering the facility name and address in the designated fields.
03
Indicate the type of renal facility by selecting the appropriate option from the provided choices.
04
Fill in the contact information of the facility, including phone number and email address.
05
Provide details about the facility's operating hours and days of operation.
06
Answer the questions regarding the facility's capacity and number of dialysis machines available.
07
Specify the type of water purification system used by the facility.
08
If applicable, provide information about any additional services offered by the facility.
09
Sign and date the form to complete the filling process.
10
Ensure all the information provided is accurate and up-to-date.
Who needs renal facility 265-2011 form?
01
Renal facility 265-2011 form is required by individuals or organizations operating a renal facility.
02
This includes dialysis centers, hospitals, clinics, or any healthcare facility that provides renal care services.
03
The form is necessary to ensure compliance with regulations and to provide essential information about the facility's operations.
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