Forms

The following are forms available from Healthcare Planning.

End-Stage Renal Disease (ESRD) Data Collection Form

Healthcare Planning's December 2024 data collection form for ESRD facilities is now available for download. This required form is used to report inventory and utilization of dialysis stations and services for the current reporting date.

Please download the form, complete all sections and return to Healthcare Planning by Friday, February 7, 2025.

  1. Complete and sign the form.
  2. Rename the workbook using the capital letters ESRD followed by the facility's Medicare provider number with no dash or space between the letters and numbers in the filename (e.g. ESRD342815).
  3. Email the Excel workbook(s) to [email protected].

If you have questions, call Elizabeth Brown in Healthcare Planning at 919-855-3865 or email [email protected].

Registration and Inventory Forms

Registration & Inventory of Equipment forms are required annually. Please complete all sections of the form for your equipment type and return to Healthcare Planning by Friday, January 24, 2025.

If you have questions, call Andrea Emanuel in Healthcare Planning at (919) 855-3954 or email [email protected].