Criteria for Payment by Kidney Disease Program

Copies of the original forms showing the following should be sent to the Kidney Disease Program at the address below:

The Department of Health and Mental Hygiene
The Kidney Disease Program
201 West Preston Street, Rm. 314 A
Baltimore, MD 21201
Tel: (410) 767-5000.

  1. ESRD Certification Number,
  2. Copy of Medicare Provider Number from CMS (Health Care Financing Administration),
  3. Medicaid Provider Number,
  4. List of Prospective Payment Rates,
  5. Treatment Modalities,
  6. Name of Intermediaries,
  7. Billing Contact Person's Name,
  8. Name and Address of Functioning Unit,
  9. Name and Address of where Kidney Disease Program payment should be forwarded, and
  10. Your Federal Tax Identification Number.