PLEASE TYPE OR PRINT LEGIBLY

Provider # 45-_______________ OR 67- _______________Facility NPI # _______________________Facility Name: _____________________________________City: _____________________________________________PLEASE TYPE OR PRINT LEGIBLYPosition Name Credentials E-MailFirst LastIndividual responsible for the completion of the CMS-2744 Annual Facility survey2744 Contact:Individual responsible for facility as a whole.Administrator/CEO:Individual responsible for the completion of all CMS data forms; person to be contacted for correctionsData Contact:Person to be contacted concerning ESRD dietitian questions and concernsDietitian:Person to be contacted in the event of a disasterDisaster Coordinator:Alternate DisasterCoordinator:Individual designated by the facility as the voting representative of the Network CouncilFacility Representative:Registered Nurse responsible for data collection and supervising facility nursing staffPLEASE NOTE:Any position that does not apply to yourfacility mark as: N/AHead Nurse/DON:Physician responsible for facility as a wholeMed. Dir.UPIN #:Medical Director:Patient (NOT facility staff) designated by the facility to serve as a primary liaison between the facility's patients and Network 14Patient Representative:Registered Head Nurse responsible for the peritoneal dialysis unitPD Nurse Coordinator:Person to be contacted for questions and concernsSocial Worker:Individual listed as Dialysis Facility Report (DFR) Master Account Holder (MAH)*Special Studies Contact:* Corporate email address specific to the individual is required for MAH updatesComplete and return to ESRD Network 14 by fax at 972-503-3219 whenever a change in key personnel occurs.Date: _______________ Prepared by: ________________________________ Title: _________________[12-19-11 I:\Facility information\New Facilities] Supporting Quality of Care

4040 McEwen Rd Suite 350Dallas, Texas 75244www.esrdnetwork.org972-503-3215 Phone972-503-3219 FaxRoster of Key Personnel Narrative2744 Contact Individual responsible for the completion of the CMS-2744 Annual Facilitysurvey.Administrator/CEOData ContactDietitianFacility RepresentativeDisasterCoordinatorAlternate DisasterCoordinatorHead Nurse/DONMedical DirectorPD Nurse CoordinatorNetwork Patient RepSocial WorkerSpecial Studies ContactIndividual responsible for facility as a wholeResponsible for the completion of all CMS data forms (2728, 2746, MissingForms, NPAR, Quarterly Event Validations); person to be contacted forcorrections (Current Rejects Report, address updates, personnel updates)Facility Dietitian to be contacted concerning ESRD dietaryquestions and concernsIndividual designated by the facility as the voting representative ofthe Network Coordinating Council (NCC)Person to be contacted in the event of a disasterAlternate person to be contacted in the event of a disasterQualified Registered Nurse responsible for data collection and forsupervising facility nursing staffPhysician responsible for facility as a wholeQualified Registered Nurse responsible for peritoneal dialysis unitPatient (NOT facility staff) designated by the facility to serve as aprimary liaison between the facility’s patients and Network 14Facility Social Worker to be contacted for questions andconcerns related to patientsIndividual designated as the Dialysis Facility Report (DFR) Master AccountHolder (MAH). Corporate email address specific to the individual is required.[12-19-11 I:\Facility information\New Facilities] Supporting Quality of Care