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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: H06BOARD MEETING: June 20, 2017PROJECT NO: 16058PROJECT
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01
Fill out the patient's name, address, phone number, and date of birth in the appropriate sections.
02
Indicate the type of dialysis treatment the patient is receiving.
03
Provide information on the patient's insurance coverage and any other relevant medical history.
04
Include details on the patient's primary care physician and any other healthcare providers involved in their treatment.
05
Sign and date the form to certify the accuracy of the information provided.

Who needs 16-058 dialysis care center?

01
Patients who are receiving dialysis treatment for kidney disease.
02
Healthcare providers who are referring patients for specialized care at a dialysis center.
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16-058 dialysis care center is a form used to report information about dialysis care centers to the relevant authorities.
All dialysis care centers are required to file the 16-058 form.
The 16-058 form should be filled out with accurate information about the dialysis care center.
The purpose of the 16-058 form is to ensure that dialysis care centers are meeting the necessary requirements and providing quality care.
Information such as number of patients, services provided, and any incidents or complaints must be reported on the 16-058 form.
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