"Your Treatment, Your Choice"

Your Treatment Your Choice

Register For Your Free CD-Rom Disk Set

Includes:

  • NKF's "Your Treatment, Your Choice"

  • RPA's "The KDE Business Resource"


PLEASE NOTE: Per the MIPPA legislation, this program can only be offered for reimbursement by "Qualified Persons" defined as: Physicians, Advanced Practice Nurses, Physician Assistants and Clinical Nurse Specialists.

All fields are required unless otherwise noted.

Discipline / Credentials: Physician
Advanced Practice Nurse
Physician Assistant
Clinical Nurse Specialist
Other:
First Name:
Last Name:
NPI Number:
Organization / Affiliation:
Office Address:
A street address is required.
No PO Boxes please.
City:
State:
Zip:
Email:
Office Phone:
Please describe your practice:
  CKD clinic
Private practice
Other:
Approximately how many CKD patients (not on dialysis ) do you see per week?
  0-25
26-50
More than 50
Who is the "Qualified Presenter" who will teach this program to patients?
  Myself
Other - If you checked "Other," please provide the person's name, discipline/credentials, and address (if different than address typed above) so we may send him/her updates, news about MIPPA, and other relevant program information.
Discipline / Credentials: Physician
Advanced Practice Nurse
Physician Assistant
Clinical Nurse Specialist
Other:
First Name:
Last Name:
Office Address:
A street address is required.
No PO Boxes please.
City:
State:
Zip:
Email:
Office Phone:
Some patients may need help finding a "Qualified Presenter" in their area. The National Kidney Foundation is compiling and publicizing a Directory on the NKF website of "Qualified Presenters" who use the NKF program "Your Treatment, Your Choice" to implement the new MIPPA patient education benefit. May we list you (or the person you indicated was a "Qualified Presenter") in the Directory?
  Yes  No

(If you checked "Yes", please complete the authorization and signature boxes below.)

I am (or the person named in the "Other Qualified Presenter" section above is) a "Qualified Presenter" who will use the National Kidney Foundation's patient education program "Your Treatment, Your Choice" to provide kidney disease education services to eligible Medicare beneficiaries with CKD stage 4 as defined by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA).
I (or the person named in the Other Qualified Presenter section above) would like the National Kidney Foundation (NKF) to list my name, affiliation, and contact information on its website for Your Treatment, Your Choice, so that eligible Medicare beneficiaries with CKD stage 4 can contact me for patient education services.
Electronic signature:
Type your name