Forms
CMS 2728
End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration.
- Required for all patients who initially receive a kidney transplant instead of a course of dialysis.
- Required for all patients for whom a regular course of dialysis has been prescribed by a physician.
- Required for beneficiaries who have already been entitled to ESRD Medicare benefits and those benefits were terminated because their coverage stopped 3 years post transplant but now are again applying for Medicare ESRD benefits because they returned to dialysis or received another kidney transplant.
- Required for beneficiaries who stopped dialysis for more than 12 months, have had their Medicare ESRD Benefits terminated and have now returned to dialysis or received a kidney transplant.
The 2728 Form original must be submitted to local SSA office and a copy to the Network within 45 days of the patient's start at a dialysis facility.
To download a copy of the 2728 Form click here . (CMS PDF opens in a new browser)
CMS 2746
End Stage Renal Disease Death Notification Form
- Required for all ESRD or Transplant patients who die within 30 days of the last chronic dialysis treatment or within 30 days after a Transplant. The facility last responsible for the patient's maintenance dialysis (or home dialysis) or for the transplant is required to submit the form to the Network.
The 2746 Form must be submitted to the Network within 30 days of the patient's death.
To download a copy of the 2746 Form click here. (CMS PDF opens in a new browser)
Patient Activity Report (PAR)
The PAR is a monthly report submitted to the Network by all dialysis facilities. This report lists any/all new patients and patient events for current patients. All admissions, discharges, transfers in or out, and modality changes are recorded so that the Network will have on-going information about patient activity.
- The PAR is due to the Network by the 10th of every month.
- Clinics are responsible for making copies of the blank form and submitting a completed month's record each month. No reminders are sent.
Click here to download a copy of the PAR form. (21 KB Excel file opens in a new browser)