Memorandum of Understanding

Our facility hereby joins other End-Stage Renal Disease (ESRD) treatment facilities in Network 15 in agreeing to participate in the activities of the Network as provided in 42 CFR Part 494.180(i) [Dialysis Facility Conditions for Coverage] or 42 CFR Part 482.104(c) [Transplant Center Conditions of Participation] of the Department of Health and Human Services regulations.

Our facility agrees to meet Network goals and participate in the activities of the Network, including data collection, quality improvement activities, resolution of grievances, consultation on cases related to involuntary discharges, and special studies. The facility also agrees to use those treatment settings most compatible with the successful rehabilitation of the patient and improvement of their quality of life, and to promote the participation of suitable patients in vocational rehabilitation programs.  It is understood that the Network is available to provide technical assistance to facilities and that participation in Network activities is a condition of approval to receive Medicare reimbursement for the provision of ESRD services.  Failure to comply may result in sanctions by the Centers for Medicare & Medicaid Services.

By signing below we acknowledge this document as an agreement between our facility and HSAG: ESRD Network 15.

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*CMS Certification Number (CCN)

*Facility Name

*Email Address

*Confirm Email Address

*Authorized Facility Representative Name

Facility Representative Signature

Date

*Chief Executive Officer, Health Services Advisory Group, Inc.

Chief Executive Signature

Date

*Enter answer to equation on left

By clicking submit, you are signing this agreement electronically. You agree your electronic signature is the equivalent of your manual signature on this agreement.