Please complete the application below to participate in the 5-Diamond Patient Safety Program. Once your application has been processed you will receive a confirmation email with further information.

Applicant Information

• Facility name:
• Medicare provider number:
• Name of project contact person (at your facility):
• Job title:
• Email address:
• Phone number:
• Number of staff in your facility (please note modules require 80-100% participation of staff):

Please indicate below the modules your facility is interested in completing:

• Patient Safety Principles (mandatory module for all participants)
• Decreasing Dialysis Patient & Provider Conflict (DPC)
• Emergency Preparedness
• Flu Vaccination
• Hand Hygiene
• Medication Reconciliation
• Missed Treatments
• Sharps Safety
• Slips, Trips, & Falls
• Other*
• * Please indicate other:

• Thank you for your dedication to patient safety issues within the dialysis community.