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 dialysis and transplant patients who expire (see form instructions).
- 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)