End-Stage Renal Disease (ESRD) Data Collection Form

Healthcare Planning's June 2015 data collection form for ESRD facilities is now available for download. This information is needed to report current utilization of in-center dialysis stations services and determine the percentage of patients receiving home dialysis in the state to project future need for new dialysis stations and facilities. Documented need for such service is a requirement in order to expand the number of facilities or stations for any county in the state.

Please download the form, complete all sections and return to Healthcare Planning by Friday, August 28, 2015.

  1. Complete and sign the form.
  2. The workbook must be renamed using the capital letters ESRD followed by the facility's Medicare provider number with no dash or space in between the letters and numbers in the filename.(e.g. ESRD342815)
  3. Email the Excel workbook to DHSR.SMFP.ESRD-Inventory@dhhs.nc.gov.


If you have questions, call Tom Dickson in Healthcare Planning at 919-855-3865 or email DHSR.SMFP.ESRD-Inventory@dhhs.nc.gov.