Southern California Renal Disease Council, Inc. Logo
Welcome to ESRD Network 18
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Our Mission

To provide leadership and assistance to renal dialysis and transplant facilities in a manner
that supports continuous improvement in patient care, outcomes, safety and satisfaction.

Forms

CMS-2728 Copy Request Form (PDF) (Word)

Forms Request

Patient Address Change Form

Network Patient Activity Report (PAR) - Transplant
DO NOT email the PAR, it must be mailed or faxed.

Network Patient Activity Report (PAR)
DO NOT email the PAR, it must be mailed or faxed.

  • Network PAR (excel format) - Excel spreadsheet can be saved onto your computer. Just go to 'File' and then 'Save As'. If you are having problems saving the PAR (excel format), please contact Patrick Ciriello, Director of Information Systems.

 

Emergency Use Forms - Please use these PDFs ONLY if forms are due within two weeks.

CMS-2728 Form (pdf)
ESRD Medical Evidence Report. Not an interactive form, only printable. REMEMBER to send a copy of this form to your local Social Security office.

CMS-2746 Form (pdf)
ESRD Death Notification. Not an interactive form, only printable.

 

* To view or download these forms, you must have the free Acrobat Reader.
Click the following icon to download the latest version: Get the Free Acrobat Reader!

 

Copyright © 2007 The Southern California Renal Disease Council / ESRD Network 18