FORM C: Home Therapies Discussion Group Sign-in Sheet Date and time Name of facilitator Facility and Medicare Provider Number (6 digit number beginning with a 45 or 67) Name of patient co-facilitator Primary language Name Signature PLEASE DO NOT EMAIL Due to ESRD Network 14: July 18, 2016. Fax to Dany Anchia, QI Coordinator at fax# 972-331-3659 NEVER EMAIL PATIENT SPECIFIC INFORMATION TO THE NETWORK. If Remember: this occurs, it will be reported to CMS as a security incident.
FORM C: Home Therapies Discussion Group Sign-in Sheet Date and time Name of facilitator Facility and Medicare Provider Number (6 digit number beginning with a 45 or 67) Name of patient co-facilitator Primary language Name Signature Due to ESRD Network 14: July 18, 2016. PLEASE DO NOT EMAIL Fax to Dany Anchia, QI Coordinator at fax# 972-331-3659 Remember: NEVER EMAIL PATIENT SPECIFIC INFORMATION TO THE NETWORK. If this occurs, it will be reported to CMS as a security incident.
2016%20Discussion%20Group%20Toolkit%20%28English%29%20Home%20Referrals.docx