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Change in Reporting Monthly Patient Activity

Patient Activity ReportEffective June 1, 2005, CMS is releasing a new Patient Activity Report (PAR). Starting June 1st, please use this form to submit patient events to Renal Network 11. All old copies of the PAR should be destroyed

We strongly urge you to complete the form electronically (vs. writing the information by hand). Because the CMS form is so small, completing it electronically makes it much more legible. This will help you to avoid receiving a follow-up phone call from Network 11 to clarify any hard-to-read data. To complete the PAR electronically:

  • Click the link below to download the new form (it is an Excel document)
  • Save it to your own computer hard drive
  • Enter patient information electronically
  • Print the completed form
  • Fax or mail the completed form back to Renal Network 11

More information about the PAR: On April 1, 2004, CMS released a new form for all dialysis facilities nationwide to use when reporting patient status changes to ESRD Networks. It replaced the monthly Patient Roster that was used by Network 11 in the past. Facilities use the PAR to submit patient events (or an indication that your facility has no changes to report) on a monthly basis. Network 11 uses the forms submitted by facilities to track patients for CMS. On a quarterly basis, Network 11 sends each facility a current patient list to cross-reference our records and assure everyone is accounted for. As always, the form is due to the Network 11 office by the 10th of the following month (i.e., May events are due on June 10).

Materials

Contact Information

Please feel free to call or Email your Network contact with questions:

Facilities in MN, ND, and SD - Sandy Schmidt
Email: sschmidt@nw11.esrd.net

Facilities in WI - Bob, Cheryl, or Sandy
Email: Please use one of the listed Email addresses.

Facilities in Detroit, MI area - Bob Schlichenmaier
Email: bschlichenmaier@nw11.esrd.net

Facilities in Greater MI - Cheryl Dickhausen
Email: cdickhausen@nw11.esrd.net