Appendix O - Emergency Dialysis Patient Record Facility: Date: _____________________________________ _______________________________________ Name: Physician: ___________________________________ ______________________________________ Address: _______________________________ ____________________________________ Social Security Number: Phone Number: ( ) ________________________ Medicare? Yes No Insurance: _____________________________ □ □ Contact Person: ______________________________ Relationship: _________________________ Address: City/State/ZIP: _______________________________ ____________________________________ Number: ( ) Usual Dialysis Facility: _________________________ Hemo □ CAPD □ Treatment Modality (Check One): IPD □ CCPD □ Transplant □ Treatment Log Date Services Provided Observations/Notes Staff Name
Appendix O - Emergency Dialysis Patient Record Facility: _____________________________________ Date: _______________________________________ Name: ______________________________________ Physician: ___________________________________ Address: ____________________________________ _______________________________ Social Security Number: ________________________ Phone Number: ( ) Medicare? □ Yes □ No Insurance: _____________________________ Contact Person: ______________________________ Relationship: _________________________ Address: ____________________________________ City/State/ZIP: _______________________________ Number: ( ) Usual Dialysis Facility: _________________________ Treatment Modality (Check One): □ Hemo □ CAPD □ IPD □ CCPD □ Transplant Treatment Log Date Services Provided Observations/Notes Staff Name
cms_disasterprep-supplementalappendix-of-customizable-forms_508.docx