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Facility Closure Form

Please use this form to notify the Network of an interruption of service at your dialysis facility. All interruptions in service, regardless of the cause or length of interruption, should be reported to the Network and your state survey agency. Please provide a brief description of the incident and a representative from the Network will contact you to gather additional information and follow-up. Alternately, you may call the Network to speak with us directly (651-644-9877). Thank you.
Describe the nature of the incident.
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Midwest Kidney Network

N1010 Overby Dr

Birchwood, WI 54817

(651) 644-9877 Phone

info@midwestkidneynetwork.org

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