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Esrd medicare application form

3427-2026

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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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Click ‘Get Form’ to open it in the editor.
Begin by selecting the type of application you are submitting in Item 1. Check all that apply, including Initial, Recertification, or any other relevant options.
Fill in the identifying information for your facility in Items 2 through 10. Ensure accuracy in the name, address, and contact details.
In Item 20, indicate the current services your facility offers by checking all applicable boxes. For new services requested, complete Item 21 accordingly.
Complete staffing details in Item 30 by listing full-time equivalents for each role. Use the provided guidelines to calculate FTEs accurately.
Finally, review all entries for accuracy and completeness before signing off on the form in Item 34. If necessary, use the Remarks section (Item 33) for additional comments.

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Versions	Form popularity	Fillable & printable
2013	4.9 Satisfied (507 Votes)

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What does k stand for in Roman Numerals?

CCCXLII Roman Numerals NumberRoman Numeral 342 CCCXLII

What is the Roman numeral for 3427?

Solution: 3427 in Roman Numerals is MMMCDXXVII.

What is a 3427 form?

A completed request for approval as a supplier of End Stage Renal Disease (ESRD) services in the Medicare program (Part I Form CMS-3427) must include a copy of the Certificate of Need approval, if such approval is required by the state. TYPE OF APPLICATION (ITEM 1)

What does mmxx mean in numbers?

VII=5 + 1 + 1 = 7 XXV = 10 + 10 + 5 = 25 IV = 5 1 = 4 IC = 100 1 = 99 VL = 50 5 = 45

What is the Roman numeral of 342?

MMXX in Roman Numerals can be written in numbers by combining the value of each Roman numeral, i.e., MMXX = M + M + X + X = 1000 + 1000 + 10 + 10 = 2020.