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Patient Change of Address Form

In compliance with HIPAA regulations, Patient Change of Address notices to Renal Network 11 will no longer be accepted via postcard. Please use the electronic form linked below to report patient address changes via fax.

We strongly urge you to complete the form electronically (vs. completing it by hand). It is much more legible and will help you to avoid receiving a follow-up phone call from Network 11 to clarify any hard-to-read data. To complete electronically:

  • Click the link below to view the form (it is an Adobe Acrobat Form)
  • Complete the fields (Name, Address, etc)
  • Click the "Print this Form" button (it will print with your information on it)
  • Fax this document to Network 11 (Fax # 651-644-9853)
  • Do not send the form via e-mail

Question:

When do you need to complete a Patient Change of Address Form?

Answer:

A Change of Address form is only necessary when a patient has a change of address (this will often coincide with a transfer-in to a new facility). You do not need to complete a Patient Change of Address form if you are sending a new 2728 to Network 11.

Patient Address Change Form (74 KB PDF form file opens in new browser)

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