U.S. Renal Care Request for Privileges

Request for Privileges

To help us better serve you, tell us a bit about who you are...
Name *

First Name Last Name
Email *
example@example.com
I am a: *

Provider Provider Group or Admin USRC Facility Administrator
I am requesting privileges for: *

Myself Another Provider

Request for Privileges

Please fill out the following information regarding the requested provider...
Provider Name *

First Name Last Name
Provider Email Address *
example@example.com
Provider Phone Number
Provider Type *
NPI *
ex: 1234567890
Office Contact

Providing an office contact (name, email, and phone) allows for the credentialing process to be completed much more time efficiently. Please take the time to locate this information.
Do you have office contact information for this provider?

Yes No
Provider Office Credentialing Contact Name
Provider Office Credentialing Contact Phone Number
Provider Office Credentialing Contact Email Address
May not be the same as the provider's email address
Location State *
AK Facility Name *
Hold down "CTRL" or "Command" to make multiple selections
AL Facility Name *
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AR Facility Name *
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AZ Facility Name *
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CA Facility Name *
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CO Facility Name *
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CT Facility Name *
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DE Facility Name *
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FL Facility Name *
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GA Facility Name *
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GU Facility Name *
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HI Facility Name *
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ID Facility Name *
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IL Facility Name *
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IA Facility Name *
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IN Facility Name *
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MA Facility Name *
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MD Facility Name *
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MI Facility Name *
MO Facility Name *
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NC Facility Name *
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NJ Facility Name *
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NM Facility Name *
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NY Facility Name *
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OH Facility Name *
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OK Facility Name *
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OR Facility Name *
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PA Facility Name *
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SC Facility Name *
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TN Facility Name *
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TX Facility Name *
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UT Facility Name *
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VA Facility Name *
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WY Facility Name *
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Is this the provider's first time being credentialed with USRC? *

Yes, this is an initial appointment No, this is a request for privileges at a new facility
Which other USRC facilities already have privileges granted?
Is there an immediate need to credential the provider in less than the standard four-week turnaround time? All expedited requests are subjected to approval from the Vice President of Medical Staff Credentialing and an expedited processing fee.

Yes No
Please explain why expedited processing is needed: *
ex: provider needs to admit a patient, provide coverage for another physician, etc.
What date will the provider will begin rounding? *

Month Day Year
Date
Today's Date

Month Day Year
Date
Dates Difference
Number of Days to Completion
Full Facility List
Once you have made your selection(s) click Submit.

Please note: Once this form has been submitted, the provider will be added to the facility and sent a connection rquest within 48 hours. Please contact credentialing@usrenalcare.com with any questions.
Should be Empty:

Apple Valley Home 1586
Berkeley 1323
Beverly Hills 0653
Carson 0606
Chula Vista 0651
Chula Vista Broadway 1503
Chula Vista Home 0605
Culver City 0614
Downtown Los Angeles 0660 and Downtown Los Angeles Home 0428
Earl Street 0666
Findlay Home 0669
Gala 0603
Gardena 0667
Grand Ave 0599 and Grand Ave Home 0600
Grand Home 0659
LA 0579 and LA Home 0580
Little Tokyo 0338
Live Oak Facility 0471
Lomita 0662
Long Beach 0581
Modesto 0585 and Modesto Home 0586
Montebello 0584
Monterey 0607 and Monterey Home 0608
Napa 1463 and Napa Home 1466
Northridge Roscoe 0612 and Northridge
North Hollywood 0169
Roscoe Home 0613
Oakdale 0587
Oceanside 1513 and Oceanside Home 1516
Ontario 0578
Pacific Gateway 0664 and Pacific Gateway Home 0665
Panorama 0622 and Panorama Home 0623
Parkway 0595
Patterson 0652
Redondo 0661
Rosemead 0583
Sherman Oaks 0617
Sherman Oaks Home 0618
Simi Valley 0592 and Simi Valley Home 0593
Skypark 0598
South Bay 0330
South Bay Home 0307
Torrance 0573
Van Nuys 0615
Verdugo Hills 0609 and Verdugo Hills Home 0610
West Coast 0574 and West Coast Home 0575
West LA 0619 and West LA Home 0620
Westside 0576 and Westside Home 0577
East Orange County 1065

Boynton Beach 0329 and Boynton Beach Home 0331
Delray Beach 0540 and Delray Beach Home 0541
Memorial West 0545
New Smyrna Beach 5183 and New Smyrna Beach Home 5186
North Tampa 5293 and North Tampa Home 5296
USRC Palmer Ranch 1143
Sarasota 5573 and Sarasota Home 5576
South Tampa 5073 and South Tampa Home 5076
Tampa Central 1183 and Tampa Central Home 1186
Uptown Naples 5589 and Uptown Naples Home 5586
Viera 5203 and Viera Home 5206
West Palm Beach 0546 and West Palm Beach Home 0436
Winkler 1055
Mustang Denovo
Fort Myers Dialysis
Fort Myers North Dialysis
Cape Coral South Dialysis
Cape Coral North Dialysis
Cape Coral Home Dialysis
Lehigh Acres Dialysis

Adel 0141
Calhoun 0142
Central Valdosta 0143
Cobb County Roswell 5043 and Cobb County Roswell Home 5046
Conyers 5083 and Conyers Home 5086
Covington 1173
Cumming 0558
Cumming Home 0559
Dalton 0261 and Dalton Home 0264
Dekalb 5283 and Dekalb Home 5286
Eisenhower 5873
Fitzgerald 0144
Forsyth 5683
Georgia Home Therapies 0655
Gray 5793
Griffin 0566 and Griffin Home 0567
Hawkinsville 0146 and Hawkinsville Home 0149
Kennesaw Home 5096
La Grange 0570 and La Grange Home 0571
Macon Clinton 5693 and Macon Clinton Home 5696
Macon Hemlock 5883
Macon Pine 5673 and Macon Pine Home 5676
Milledgeville 5783
Monroe 1083 and Monroe Home 1086
Monticello 5973
Murray County 0262
Paulding Home 5376
Roswell 0564 and Roswell Home 0565
Royston 0147
Savannah 5503 and Savannah Home 5506
Snellville 1063 and Snellville Home 1066
Social Circle 5273 and Social Circle Home 5276
South Georgia 0148
Valdosta Home 0283
Winder 0304 and Winder Home 0305
Woodstock 1543 and Woodstock Home 1546
Northwest Georgia Home 1012

Alexis 0507
Barberton 0195
Blanchard Valley 0437 and Blanchard Valley Home 0438
Briarfield Home 0432
Cincinnati (Mt Healthy) 0182 and Cincinnati (Mt Healthy) Home 0192
Cuyahoga 0315
Defiance 0528
Delaware County 0184 and Delaware County Home 0191
Fremont 0531
Kent Dialysis 0351
Kenwood 0186 and Kenwood Home 0193
Maumee 0349
Northwest Ohio 0529
Norton Home Therapies 0196
Norwood 0187
Sylvania 0508
Talmadge Home 0412
Toledo (Bowling Green) 0181
Wildwood 0506
USRC Tiffin 0488 and Tiffin Home 0654
USRC Findlay Home 0669

Amarillo 0500 and Amarillo Home 0501
Arlington 0041
Atascosa County 0032 and Atascosa County Home 0075
Azle 0054
Bandera Road 0033 and Bandera Road Home 0071
Baylor Scott Street 0080
Beeville 1423 and Beeville Home 1426
Boerne 0031
Bryan 2203 and Bryan Home 2206
Bryant Irvin 0282
Burleson 0311 and Burleson Home 0395
Canton 0088
Central Fort Worth 0040
Central SA 0392
Chinatown 2283 and Chinatown Home 2286
Cleburne 0053
Conway 0376
Downtown San Antonio 0115
East Dallas 1673 and East Dallas Home 1676
East El Paso 2173 and East El Paso Home 2176
East Fort Worth 0058
East Plano 0286
Eastland 2373 and Eastland Home 2376
Edinburg 0024
Elsa (Delta) 0060
Flower Mound 0276
Fort Worth 0043
Friendswood 0084
Gateway 0034
Grand Prairie 0045
Harlingen 0020 and Harlingen Home 0063
Hill Country 0439
Houston Home Therapies 0082
Houston St 0030 and Houston St Home 0070
Keller 0277
Kingwood 0081 and Kingwood Home 0118
Laredo 0022
Laredo South 0029 and Laredo South Home 0069
Las Canteras 0377 and Las Canteras Home 0408
Liberty Cedar Hill 0420 and Liberty Cedar Hill Home 0422
Liberty Charlton 0353
Liberty Duncanville 0354 and Liberty Duncanville Home 0355
Liberty Gaston 0367 and Liberty Gaston Home 0405
Liberty Lancaster 0356
Liberty Mansfield 0357 and Liberty Mansfield Home 0380
Liberty Mesquite 0358 and Liberty Mesquite Home 0359
Liberty Richardson 0360 and Liberty Richardson Home 0361
Liberty Rockwall 0362
Liberty Waxahachie 0363 and Liberty Waxahachie Home 0364
Liberty West Grand Prairie 0421 and Liberty West Grand Prairie Home 0424
Liberty Wylie 0365 and Liberty Wylie Home 0366
Lubbock 0513 and Lubbock Home 0514
Mansfield 0046
Maverick County 0039 and Maverick County Home 0072
McAllen 0021
Meadows Place 1163 and Meadows Place Home 1166
Med Center 0303
Medina 0035
Mid Valley Weslaco 0026
Mineral Wells 0055
Mission 0023
North Dallas 0016 and North Dallas Home 0017
North El Paso 2083 and North El Paso Home 2086
North Fort Worth 0044
North Lubbock 0306
North Richland Hills 0049
Oso Bay 2093 and Oso Bay Home 2096
Plano 0012
Pleasanton Road 0076
Premier 1983 and Premier Home 1986
Richardson 0316
Rio Grande 0025
Rowlett 0339
Royal Central 0235
San Antonio Home Therapies 0114
San Benito 0028 and San Benito Home 0372
San Saba 0392
Schertz 0511
South El Paso 2073
South Fort Worth 0042
South San Antonio 0121
Southeast San Antonio 0390 and Southeast San Antonio Home 0391
Southwest Fort Worth 0050
Space City - Pasadena 1973 and Space City - Pasadena Home 1976
Sunnyvale 0478
Tarrant County PD 0047
Tri-County 0037
Valley McAllen 0027 and Valley McAllen Home 0067
Weatherford 0048
Webster 2273 and Webster Home 2276
West El Paso 2003
West Fork 0639
West Fort Worth 0052
West University 0310
Westover Hills 0116
Physicians Services
South Arlington 0237 and South Arlington Home 1126
Liberty Plano Dexter 0238
Data Point 0199
Stadium Home 1046
Dialysis At Home
North Harlingen 1011
Conroe 0098 and Conroe Home 0107
Double Springs 1005
Bluebonnet 1016
Bluebonnet Home 1017
Liberty McKinney 1050 and Liberty McKinney Home 1051
Liberty Stephenville 0236 and Liberty Stephenville 1117
Liberty Garland 1052

Request for Privileges

Request for Privileges

Office Contact