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Esrd medicare application form

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The document is a form (CMS-3427) from the Department of Health and Human Services, specifically for the Centers for Medicare & Medicaid Services. It serves as an application and survey certification report for facilities providing End Stage Renal Disease (ESRD) services. The form requires detailed information about the facility, including its type of application, ownership, services offered, staffing details, and compliance with state licensing requirements. It also outlines the necessary documentation needed to process the application and includes sections for both the facility's administrator and state agency review.

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