Crosswalk

Crosswalk of Changes For Form CMS-3427 End Stage Renal Disease Application and Survey and Certification Report

Item	Page	Section	Changes to Application	Reason for Change	Action/comments
1-CMS Form 3427	4	Instructions for Form CMS 3427 - Types of Modalities/Services, Dialysis Stations, And Days/Hours of Operation (ITEMS 20-29)	Item 22: Previous package language - Item 22 and list for all LTCs: name, CCN, staffing provided by, and number of dialysis patients treated by modality under Remarks (Item 33). New requests for dialysis within any LTC facility require completion of Item 22 (and 33 if applicable) and submission of this form to the State agency prior to survey. Item 22: Revised language (current package) - Item 22 and list for all LTCs: name, CCN, staffing provided by, and number of dialysis patients treated by modality under Remarks (Item 33). Notifications of any agreement initiated between the facility and a LTC facility for providing home dialysis to residents within any LTC facility require completion of Item 22 (and 33 if applicable) and submission of this form to the State agency .	Revised grammar for clarification. This does not impact or change the previous data collection requirements for the CMS Form 3427