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STATE OF ILLINOISHEALTH FACILITIES AND SERVICES REVIEW BOARD
525 WEST JEFFERSON ST.SPRINGFIELD, ILLINOIS 62761(217)7823516 FAX: (217) 7854111DOCKET NO:
I04BOARD MEETING:
January 9, 2018PROJECT NO:
17016PROJECT
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01
To fill out the 17-016 Salt Creek Dialysis-Supplemental2 form, follow these steps:
02
Obtain the form from the designated source.
03
Read the instructions and requirements carefully.
04
Gather all necessary information and documents related to the supplemental dialysis treatment.
05
Input the patient's personal details, including name, address, contact information, and identification number.
06
Provide the details of the primary dialysis treatment and the specific reason for requiring supplemental treatment at Salt Creek Dialysis.
07
Fill in any medical history or relevant medical information related to the patient's condition.
08
Indicate the desired timeframe and duration for receiving the supplemental treatment.
09
Sign and date the form in the designated sections.
10
Review the filled form for accuracy and completeness.
11
Submit the completed form to the appropriate authority or institution for processing.
Who needs 17-016 salt creek dialysis-supplemental2?
01
The 17-016 Salt Creek Dialysis-Supplemental2 form is required for individuals who require supplemental dialysis treatment at Salt Creek Dialysis. This form is for individuals who have already been undergoing primary dialysis treatment and require additional or supplemental treatment at Salt Creek Dialysis facility.
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What is 17-016 salt creek dialysis-supplemental2?
17-016 salt creek dialysis-supplemental2 is a supplemental form related to the Salt Creek Dialysis center.
Who is required to file 17-016 salt creek dialysis-supplemental2?
The administration or management of the Salt Creek Dialysis center is required to file 17-016 salt creek dialysis-supplemental2.
How to fill out 17-016 salt creek dialysis-supplemental2?
To fill out 17-016 salt creek dialysis-supplemental2, the required information must be accurately provided in the designated sections of the form.
What is the purpose of 17-016 salt creek dialysis-supplemental2?
The purpose of 17-016 salt creek dialysis-supplemental2 is to provide supplemental information related to the operations or services of the Salt Creek Dialysis center.
What information must be reported on 17-016 salt creek dialysis-supplemental2?
Information such as financial data, patient statistics, and operational details may need to be reported on 17-016 salt creek dialysis-supplemental2.
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