1. Center name *
2. Address *
4. City *
5. State * Select a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
6. Zip *
7. Phone *
8. Fax

1. Owner *
2. Provider number *
3. Medical director
4. Contact *
5. Contact e-mail *
6. Website

1. MEI will invoice you after receiving your submission. Is the person to invoice the same as above?

   Yes No

2. If no, please enter the invoice contact information here:

1. Tell us which modalities you offer, and how many patients you have for each modality.

   CAPD CCPD/APD Conventional home hemo Daily home hemo Nocturnal home hemo Staff-assisted In-center nocturnal
2. Number of home-training staff

1. Monday AM PM to PM AM
2. Tuesday AM PM to PM AM
3. Wednesday AM PM to PM AM
4. Thursday AM PM to PM AM
5. Friday AM PM to PM AM
6. Saturday AM PM to PM AM
7. Sunday AM PM to PM AM

1. Do you offer free parking?

   Yes No

2. Do you accept traveling patients?

   Yes No

Portray your center in paragraph form with facts by considering the following questions:

• When did your center begin offering training for home dialysis?
• What types/brands/models of equipment do you support?
• How is home dialysis equipment maintained?
• How often do you see your home dialysis patients in clinic?
• How do patients obtain dietitian and social worker support?
• What do you do to accommodate working patients who want to train for home dialysis?
• What percent of your home hemo patients have fistulas versus grafts or catheters?
• What is the average length of time between peritonitis bouts for your PD patients?
• What percent of your 18-64 year old patients are working full- or part-time for pay?
• How do you offer support for patient questions and emergencies?
• Do you offer in-center back-up dialysis?

MEI reserves the right to delete or edit references that compare your center to others.

1. Description

You can submit a photo to accompany your premier listing. This photo can be of your staff, office, or patients. Photos must be in .jpg or .tif format and at least 150dpi to be submitted electronically. Landscape (horizontal) photos work best.

1. Do you have a photo to include?

   Yes No

2. You will be provided with instructions for electronically submitting a photo on the next page.

Type the letters and numbers you see in this image in the box below using only CAPITAL letters and the numbers 1-9 to complete the image verification. *