Form CMS-2728 END STAGE RENAL DISEASE MEDICAL EVIDENCE REPORT MEDICARE

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No. 0938-0046

END STAGE RENAL DISEASE MEDICAL EVIDENCE REPORT
MEDICARE ENTITLEMENT AND/OR PATIENT REGISTRATION
Check one:

A. COMPLETE FOR ALL ESRD PATIENTS

■ Initial

■ Re-entitlement

■ Supplemental

1. Name (Last, First, Middle Initial)
2. Medicare Claim Number

3. Social Security Number

4. Date of Birth
MM

5. Patient Mailing Address (Include City, State and Zip)

(
7. Sex

8. Ethnicity

■ Male ■ Female

DD

YYYY

6. Phone Number

)
9. Country/Area of Origin or Ancestry

■ Not Hispanic or Latino

10. Race (Check all that apply)
■ White
■ Black or African American
■ American Indian/Alaska Native

■ Hispanic or Latino (Complete Item 9)
11. Is patient applying for ESRD
Medicare coverage?

■ Asian
■ Native Hawaiian or Other Pacific Islander*

■ Yes

■ No

*complete Item 9

Print Name of Enrolled/Principal Tribe _________________

14. Dry Weight
15. Primary Cause of Renal
12. Current Medical Coverage (Check all that apply)
13. Height
Failure (Use code from back of form)
■ Medicaid ■ Medicare ■ Employer Group Health Insurance
INCHES _______ OR
POUNDS _______ OR
KILOGRAMS _______
CENTIMETERS _______ _
■ DVA
■ Medicare Advantage
■ Other
■ None
16. Employment Status (6 mos prior and
17. Co-Morbid Conditions (Check all that apply currently and/or during last 10 years) *See instructions
current status)
a. ■ Congestive heart failure
n. ■ Malignant neoplasm, Cancer
nt
b. ■ Atherosclerotic heart disease ASHD
o. ■ Toxic nephropathy
e
r
r
io ur
r
c.
Other
cardiac
disease
p. ■ Alcohol dependence
■
P C
d. ■ Cerebrovascular disease, CVA, TIA*
q. ■ Drug dependence*
■ ■ Unemployed
e. ■ Peripheral vascular disease*
r. ■ Inability to ambulate
■ ■ Employed Full Time
f. ■ History of hypertension
s. ■ Inability to transfer
■ ■ Employed Part Time
g. ■ Amputation
t. ■ Needs assistance with daily activities
■ ■ Homemaker
h. ■ Diabetes, currently on insulin
u. ■ Institutionalized
■ 1. Assisted Living
■ ■ Retired due to Age/Preference i. ■ Diabetes, on oral medications
■ 2. Nursing Home
j. ■ Diabetes, without medications
■ ■ Retired (Disability)
■ 3. Other Institution
k. ■ Diabetic retinopathy
■ ■ Medical Leave of Absence
l. ■ Chronic obstructive pulmonary disease
v. ■ Non-renal congenital abnormality
m. ■ Tobacco use (current smoker)
w. ■ None
■ ■ Student
18. Prior to ESRD therapy:
a.
b.
c.
d.

Did patient receive exogenous erythropoetin or equivalent?
Was patient under care of a nephrologist?
Was patient under care of kidney dietitian?
For hemodialysis patients only, what access was used on
first outpatient dialysis?
If not AVF, then: Is maturing AVF present?
Is maturing graft present?

■ Yes
■ Yes
■ Yes

■ AVF
■ Yes
■ Yes
19. Laboratory Values Within 45 Days Prior to the Most Recent ESRD

LABORATORY TEST

VALUE

■ No
■ No
■ No

■ Unknown
■ Unknown
■ Unknown

If Yes
If Yes
If Yes

■ < 6 months
■ < 6 months
■ < 6 months

■ 6-12 months
■ 6-12 months
■ 6-12 months

■ >12 months
■ >12 months
■ >12 months

■ Graft ■ Catheter
■ Other
■ No
■ No
Episode. (Lipid Profile within 1 Year of Most Recent ESRD Episode).

DATE

LABORATORY TEST

a.1. Serum Albumin (g/dl)

___ . ___

d. HbA1c

a.2. Serum Albumin Lower Limit

___ . ___

e. Lipid Profile

VALUE

DATE

___ ___ . ___%
TC

___ ___ ___

a.3. Lab Method Used (BCG or BCP)

LDL

___ ___ ___

b.

Serum Creatinine (mg/dl)

___ ___ . ___

HDL

c.

Hemoglobin (g/dl)

___ ___ . ___

TG

___ ___
___ ___ ___ ___

B. COMPLETE FOR ALL ESRD PATIENTS IN DIALYSIS TREATMENT
21. Medicare Provider Number (for item 20)

20. Name of Dialysis Facility
22. Primary Dialysis Setting
■ Home ■ Dialysis Facility/Center

■ SNF/Long Term Care Facility

24. Date Regular Chronic Dialysis Began
MM

26. Has patient been informed of kidney transplant options?
■ Yes
■ No

FORM CMS-2728-U3 (03/06)

DD

YYYY

23. Primary Type of Dialysis
■ Hemodialysis (Sessions per week____/hours per session____)
■ CAPD
■ CCPD
■ Other
25. Date Patient Started Chronic
Dialysis at Current Facility
MM
DD
YYYY
27. If patient NOT informed of transplant options, please check all that apply:
■ Medically unfit
■ Patient declines information
■ Unsuitable due to age ■ Patient has not been assessed
■ Psychologically unfit
■ Other

C. COMPLETE FOR ALL KIDNEY TRANSPLANT PATIENTS
28. Date of Transplant
MM

DD

29. Name of Transplant Hospital

30. Medicare Provider Number for Item 29

YYYY

Date patient was admitted as an inpatient to a hospital in preparation for, or anticipation of, a kidney transplant prior to the date of
actual transplantation.
31. Enter Date

32. Name of Preparation Hospital
MM

DD

33. Medicare Provider number for Item 32

YYYY

34. Current Status of Transplant (if functioning, skip items 36 and 37)
■ Functioning
■ Non-Functioning

35. Type of Donor:
■ Deceased

36. If Non-Functioning, Date of Return to Regular Dialysis

37. Current Dialysis Treatment Site
■ Home ■ Dialysis Facility/Center

MM

DD

■ Living Related

■ Living Unrelated

■ SNF/Long Term Care Facility

YYYY

D. COMPLETE FOR ALL ESRD SELF-DIALYSIS TRAINING PATIENTS (MEDICARE APPLICANTS ONLY)
38. Name of Training Provider

39. Medicare Provider Number of Training Provider (for Item 38)

40. Date Training Began

41. Type of Training

MM

DD

YYYY

42. This Patient is Expected to Complete (or has completed) Training
and will Self-dialyze on a Regular Basis.
■ Yes

■ Hemodialysis

a. ■ Home b. ■ In Center

■ CAPD
■ CCPD
■ Other
43. Date When Patient Completed, or is Expected to Complete, Training

■ No

MM

DD

YYYY

I certify that the above self-dialysis training information is correct and is based on consideration of all pertinent medical,
psychological, and sociological factors as reflected in records kept by this training facility.
44. Printed Name and Signature of Physician personally familiar with the patient’s training
a.) Printed Name

b.) Signature

c.) Date

MM

45. UPIN of Physician in Item 44
DD

YYYY

E. PHYSICIAN IDENTIFICATION
46. Attending Physician (Print)

47. Physician’s Phone No. 48. UPIN of Physician in Item 46

(

)

PHYSICIAN ATTESTATION
I certify, under penalty of perjury, that the information on this form is correct to the best of my knowledge and belief. Based on diagnostic
tests and laboratory findings, I further certify that this patient has reached the stage of renal impairment that appears irreversible and
permanent and requires a regular course of dialysis or kidney transplant to maintain life. I understand that this information is intended for
use in establishing the patient’s entitlement to Medicare benefits and that any falsification, misrepresentation, or concealment of essential
information may subject me to fine, imprisonment, civil penalty, or other civil sanctions under applicable Federal laws.
49. Attending Physician’s Signature of Attestation (Same as Item 46)

51. Physician Recertification Signature

50. Date
MM

DD

YYYY

MM

DD

YYYY

52. Date

53. Remarks

F. OBTAIN SIGNATURE FROM PATIENT

I hereby authorize any physician, hospital, agency, or other organization to disclose any medical records or other
information about my medical condition to the Department of Health and Human Services for purposes of reviewing my
application for Medicare entitlement under the Social Security Act and/or for scientific research.
54. Signature of Patient (Signature by mark must be witnessed.)

55. Date
MM

DD

YYYY

G. PRIVACY STATEMENT
The collection of this information is authorized by Section 226A of the Social Security Act. The information provided will be used to determine if an individual is entitled to
Medicare under the End Stage Renal Disease provisions of the law. The information will be maintained in system No. 09-70-0520, “End Stage Renal Disease Program
Management and Medical Information System (ESRD PMMIS)”, published in the Federal Register, Vol. 67, No. 116, June 17, 2002, pages 41244-41250 or as updated and
republished. Collection of your Social Security number is authorized by Executive Order 9397. Furnishing the information on this form is voluntary, but failure to do so may
result in denial of Medicare benefits. Information from the ESRD PMMIS may be given to a congressional office in response to an inquiry from the congressional office made
at the request of the individual; an individual or organization for research, demonstration, evaluation, or epidemiologic project related to the prevention of disease or
disability, or the restoration or maintenance of health. Additional disclosures may be found in the Federal Register notice cited above. You should be aware that P.L.100-503,
the Computer Matching and Privacy Protection Act of 1988, permits the government to verify information by way of computer matches.
FORM CMS-2728-U3 (03/06)

LIST OF PRIMARY CAUSES OF END STAGE RENAL DISEASE
Item 15. Primary Cause of Renal Failure should be completed by the attending physician from the list below. Enter the
ICD-9-CM code to indicate the primary cause of end stage renal disease. If there are several probable causes of renal failure,
choose one as primary. Code effective as of September 2003.

ICD-9

NARRATIVE

ICD-9

NARRATIVE

DIABETES

CYSTIC/HEREDITARY/CONGENITAL DISEASES

25040
25041

75313
75314
75316
7595
7598
2700
2718
2727
7533
5839
75321
75322
75329
7530
75671
75989

Diabetes with renal manifestations Type 2
Diabetes with renal manifestations Type 1

GLOMERULONEPHRITIS
5829
5821
5831
58321
58322
58381
58382
5834
5800
5820

Glomerulonephritis (GN)
(histologically not examined)
Focal glomerulosclerosis, focal sclerosing GN
Membranous nephropathy
Membranoproliferative GN type 1, diffuse MPGN
Dense deposit disease, MPGN type 2
IgA nephropathy, Berger’s disease
(proven by immunofluorescence)
IgM nephropathy (proven by immunofluorescence)
With lesion of rapidly progressive GN
Post infectious GN, SBE
Other proliferative GN

Polycystic kidneys, adult type (dominant)
Polycystic, infantile (recessive)
Medullary cystic disease, including nephronophthisis
Tuberous sclerosis
Hereditary nephritis, Alport’s syndrome
Cystinosis
Primary oxalosis
Fabry’s disease
Congenital nephrotic syndrome
Drash syndrome, mesangial sclerosis
Congenital obstruction of ureterpelvic junction
Congenital obstruction of uretrovesical junction
Other Congenital obstructive uropathy
Renal hypoplasia, dysplasia, oligonephronia
Prune belly syndrome
Other (congenital malformation syndromes)

NEOPLASMS/TUMORS
SECONDARY GN/VASCULITIS
7100
2870
7101
28311
4460
4464
58392
44620
44621
58391

Lupus erythematosus, (SLE nephritis)
Henoch-Schonlein syndrome
Scleroderma
Hemolytic uremic syndrome
Polyarteritis
Wegener’s granulomatosis
Nephropathy due to heroin abuse and related drugs
Other Vasculitis and its derivatives
Goodpasture’s syndrome
Secondary GN, other

INTERSTITIAL NEPHRITIS/PYELONEPHRITIS
9659
5830
9849
5909
27410
5920
5996
5900
58389
58089
5929
27549

Analgesic abuse
Radiation nephritis
Lead nephropathy
Nephropathy caused by other agents
Gouty nephropathy
Nephrolithiasis
Acquired obstructive uropathy
Chronic pyelonephritis, reflux nephropathy
Chronic interstitial nephritis
Acute interstitial nephritis
Urolithiasis
Other disorders of calcium metabolism

HYPERTENSION/LARGE VESSEL DISEASE
40391
4401
59381
59383

Unspecified with renal failure
Renal artery stenosis
Renal artery occlusion
Cholesterol emboli, renal emboli

FORM CMS-2728-U3 (03/06)

1890
1899
2230
2239
23951
23952
20280
20300
20308
2773
99680
99681
99682
99683
99684
99685
99686
99687
99689

Renal tumor (malignant)
Urinary tract tumor (malignant)
Renal tumor (benign)
Urinary tract tumor (benign)
Renal tumor (unspecified)
Urinary tract tumor (unspecified)
Lymphoma of kidneys
Multiple myeloma
Other immuno proliferative neoplasms
(including light chain nephropathy)
Amyloidosis
Complications of transplanted organ unspecified
Complications of transplanted kidney
Complications of transplanted liver
Complications of transplanted heart
Complications of transplanted lung
Complications of transplanted bone marrow
Complications of transplanted pancreas
Complications of transplanted intestine
Complications of other specified transplanted organ

MISCELLANEOUS CONDITIONS
28260
28269
64620
042
8660
5724
5836
59389
7999

Sickle cell disease/anemia
Sickle cell trait and other sickle cell (HbS/Hb other)
Post partum renal failure
AIDS nephropathy
Traumatic or surgical loss of kidney(s)
Hepatorenal syndrome
Tubular necrosis (no recovery)
Other renal disorders
Etiology uncertain

INSTRUCTIONS FOR COMPLETION OF END STAGE RENAL DISEASE MEDICAL EVIDENCE REPORT
MEDICARE ENTITLEMENT AND/OR PATIENT REGISTRATION
For whom should this form be completed:
This form SHOULD NOT be completed for those patients who
are in acute renal failure. Acute renal failure is a condition in
which kidney function can be expected to recover after a short
period of dialysis, i.e., several weeks or months.
This form MUST BE completed within 45 days for ALL patients
beginning any of the following:
Check the appropriate block that identifies the reason for
submission of this form.

Initial
For all patients who initially receive a kidney transplant instead of
a course of dialysis.
For patients for whom a regular course of dialysis has been
prescribed by a physician because they have reached that stage
of renal impairment that a kidney transplant or regular course of
dialysis is necessary to maintain life. The first date of a regular
course of dialysis is the date this prescription is implemented
whether as an inpatient of a hospital, an outpatient in a dialysis

center or facility, or a home patient. The form should be
completed for all patients in this category even if the patient dies
within this time period.

Re-entitlement
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.
For beneficiaries who stopped dialysis for more than 12 months,
have had their Medicare ESRD benefits terminated and now
returned to dialysis or received a kidney transplant. These
patients will be reapplying for Medicare ESRD benefits.

Supplemental
Patient has received a transplant or trained for self-care dialysis
within the first 3 months of the first date of dialysis and initial
form was submitted.

All items except as follows: To be completed by the attending physician, head nurse, or social worker involved in this patient's
treatment of renal disease.
Items 15, 17-18, 26-27, 49-50: To be completed by the attending physician.
Item 44: To be signed by the attending physician or the physician familiar with the patient's self-care dialysis training.
Items 54 and 55: To be signed and dated by the patient.
1.

Enter the patient’s legal name (Last, first, middle initial). Name
should appear exactly the same as it appears on patient’s social
security or Medicare card.

2.

If the patient is covered by Medicare, enter his/her Medicare claim
number as it appears on his/her Medicare card.

3.

Enter the patient’s own social security number. This number can
be verified from his/her social security card.

4.

Enter patient’s date of birth (2-digit Month, Day, and 4-digit Year).
Example 07/25/1950.

5.

Enter the patient’s mailing address (number and street or post
office box number, city, state, and ZIP code.)

6.

Enter the patient’s home area code and telephone number.

7.

Check the appropriate block to identify sex.

8.

Check the appropriate block to identify ethnicity. Definitions of the
ethnicity categories for Federal statistics are as follows:
Not Hispanic or Latino—A person of culture or origin not
described below, regardless of race.
Hispanic or Latino—A person of Cuban, Puerto Rican, Mexican,
South or Central American culture or origin regardless of race.
Please complete Item 9 and provide the country, area of origin, or
ancestry to which the patient claims to belong.

9.

10.

Check the appropriate block(s) to identify race. Definitions of the
racial categories for Federal statistics are as follows:
White—A person having origins in any of the original white
peoples of Europe, the Middle East or North Africa.
Black or African American—A person having origins in any of
the black racial groups of Africa. This includes native-born Black
Americans, Africans, Haitians and residents of non-Spanish
speaking Caribbean Islands of African descent.
American Indian/Alaska Native—A person having origins in any
of the original peoples of North America and South America
(including Central America) and who maintains tribal affiliation or
community attachment. Print the name of the enrolled or principal
tribe to which the patient claims to be a member.
Asian—A person having origins in any of the original peoples of
the Far East, Southeast Asia or the Indian subcontinent including,
for example, Cambodia, China, India, Japan, Korea, Malaysia,
Pakistan, the Philippine Islands, Thailand and Vietnam.
Native Hawaiian or Other Pacific Islander—A person having
origins in any of the original peoples of Hawaii, Guam, Samoa,
or other Pacific Islands. Please complete Item 9 and provide the
country, area of origin, or ancestry to which the patient claims
to belong.

Country/Area of origin or ancestry—Complete if information is
available or if directed to do so in question 8.

DISTRIBUTION OF COPIES:
• Forward the first part (blue) of this form to the Social Security office servicing the claim.
• Forward the second part (green) of this form to the ESRD Network Organizations.
• Retain the last part (white) in the patient's medical records file.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information is 0938-0046. The time required to complete this information collection estimated to average 45 minutes per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, Attention: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
FORM CMS-2728-U3 (03/06)

11.

Check the appropriate yes or no block to indicate if patient is
applying for ESRD Medicare. Note: Even though a person may
already be entitled to general Medicare coverage, he/she
should reapply for ESRD Medicare coverage.

12.

Check all the blocks that apply to this patient’s current medical
insurance status.

19a2. Enter the lower limit of the normal range for serum albumin
from the laboratory which performed the serum albumin test
entered in 19a1.

Medicaid—Patient is currently receiving State Medicaid benefits.

19a3. Enter the serum albumin lab method used (BCG or BCP).

Medicare—Patient is currently entitled to Federal Medicare benefits.

19b. Enter the serum creatinine value (mg/dl) and date test was taken.
THIS FIELD MUST BE COMPLETED within 45 days of the date
the patient started chronic treatment in a dialysis facility or within
45 days prior to receiving a transplant.

Employer Group Health Insurance—Patient receives medical
benefits through an employee health plan that covers employees,
former employees, or the families of employees or former
employees.
DVA—Patient is receiving medical care from a Department of
Veterans Affairs facility.

13.

14.

19a1. Enter the serum albumin value (g/dl) and date test was taken.
This value and date must be within 45 days prior to first dialysis
treatment or kidney transplant.

19c. Enter the hemoglobin value (g/dl) and date test was taken. This
value and date must be within 45 days prior to the first dialysis
treatment or kidney transplant.

Medicare Advantage—Patient is receiving medical benefits
under a Medicare Advantage organization.

19d. Enter the HbA1c value and the date the test was taken. The date
must be within 1 year prior to the first dialysis treatment or kidney
transplant.

Other Medical Insurance—Patient is receiving medical benefits
under a health insurance plan that is not Medicare, Medicaid,
Department of Veterans Affairs, HMO/M+C organization, nor an
employer group health insurance plan. Examples of other medical
insurance are Railroad Retirement and CHAMPUS beneficiaries.

19e. Enter the Lipid Profile values and date test was taken. These
values: TC–Total Cholesterol; LDL–LDL Cholesterol; HDL–HDL
Cholesterol; TG–Triglycerides, and date must be within 1 year
prior to the first dialysis treatment or kidney transplant.

None—Patient has no medical insurance plan.

20.

Enter the name of the dialysis facility where patient is currently
receiving care and who is completing this form for patient.

21.

Enter the 6-digit Medicare identification code of the dialysis facility
in item 20.

22.

If the person is receiving a regular course of dialysis treatment,
check the appropriate anticipated long-term treatment setting
at the time this form is being completed.

23.

If the patient is, or was, on regular dialysis, check the
anticipated long-term primary type of dialysis: Hemodialysis,
(enter the number of sessions prescribed per week and the hours
that were prescribed for each session), CAPD (Continuous
Ambulatory Peritoneal Dialysis) and CCPD (Continuous Cycling
Peritoneal Dialysis), or Other. Check only one block. NOTE:
Other has been placed on this form to be used only to report IPD
(Intermittent Peritoneal Dialysis) and any new method of dialysis
that may be developed prior to the renewal of this form by Office
of Management and Budget.

24.

Enter the date (month, day, year) that a "regular course of chronic
dialysis” began. The beginning of the course of dialysis is counted
from the beginning of regularly scheduled dialysis necessary for
the treatment of end stage renal disease (ESRD) regardless of the
dialysis setting. The date of the first dialysis treatment after the
physician has determined that this patient has ESRD and has
written a prescription for a “regular course of dialysis” is the “Date
Regular Chronic Dialysis Began” regardless of whether this
prescription was implemented in a hospital/ inpatient, outpatient,
or home setting and regardless of any acute treatments received
prior to the implementation of the prescription.

Enter the patient’s most recent recorded height in inches OR
centimeters at time form is being completed. If entering height in
centimeters, round to the nearest centimeter. Estimate or use last
known height for those unable to be measured. (Example of
inches - 62. DO NOT PUT 5’2") NOTE: For amputee patients,
enter height prior to amputation.
Enter the patient’s most recent recorded dry weight in pounds OR
kilograms at time form is being completed. If entering weight in
kilograms, round to the nearest kilogram.

NOTE: For amputee patients, enter actual dry weight.
15.

To be completed by the attending physician. Enter the ICD-9CM from back of form to indicate the primary cause of end stage
renal disease. These are the only acceptable causes of end stage
renal disease.

16.

Check the first box to indicate employment status 6 months prior
to renal failure and the second box to indicate current
employment status. Check only one box for each time period.
If patient is under 6 years of age, leave blank.

17.

To be completed by the attending physician. Check all
co-morbid conditions that apply.
*Cerebrovascular Disease includes history of stroke/
cerebrovascular accident (CVA) and transient ischemic attack (TIA).
*Peripheral Vascular Disease includes absent foot pulses, prior
typical claudication, amputations for vascular disease, gangrene
and aortic aneurysm.
*Drug dependence means dependent on illicit drugs.

18.

Prior to ESRD therapy, check the appropriate box to indicate whether
the patient received Exogenous erythropoetin (EPO) or equivalent,
was under the care of a nephrologist and/or was under the care of a
kidney dietitian. Provide vascular access information as to the type of
access used (Arterio-Venous Fistula (AVF), graft, catheter (including
port device) or other type of access) when the patient first received
outpatient dialysis. If an AVF access was not used, was a maturing
AVF or graft present?

NOTE: For those patients re-entering the Medicare program after
benefits were terminated, Items 19a thru 19c should contain initial
laboratory values within 45 days prior to the most recent ESRD
episode. Lipid profiles and HbA1c should be within 1 year of the
most recent ESRD episode. Some tests may not be required for
patients under 21 years of age.

FORM CMS-2728-U3 (03/06)

NOTE: For these purposes, end stage renal disease means
irreversible damage to a person’s kidneys so severely affecting
his/her ability to remove or adjust blood wastes that in order to
maintain life he or she must have either a course of dialysis or a
kidney transplant to maintain life.
If re-entering the Medicare program, enter beginning date of the
current ESRD episode. Note in Remarks, Item 53, that patient is
restarting dialysis.
25.

Enter date patient started chronic dialysis at current facility for
dialysis services. In cases where patient transferred to current
dialysis facility, this date will be after the date in Item 24.

26.

Enter whether the patient has been informed of their options for
receiving a kidney transplant.

27.

If the patient has not been informed of their options (answered
“no” to Item 26), then enter all reasons why the patient was not
informed of the option of kidney transplantation.

42.

Check the appropriate block as to whether or not the physician
certifies that the patient is expected to complete the training
successfully and self-dialyze on a regular basis.

28.

Enter the date of the patient’s transplant. If reentering the Medicare
program, enter current transplant date.

43.

Enter date patient completed or is expected to complete selfdialysis training.

29.

Enter the name of the hospital where the patient received a kidney
transplant on the date in Item 28.

44.

Enter printed name and signature of the attending physician or the
physician familiar with the patient’s self-care dialysis training.

30.

Enter the 6-digit Medicare identification code of the hospital in
Item 29 where the patient received a kidney transplant on the date
entered in Item 28.

45.

Enter the Unique Physician Identification Number (UPIN) of
physician in Item 44. (See Item 48 for explanation of UPIN.)

46.

31.

Enter date patient was admitted as an inpatient to a hospital in
preparation for, or anticipation of, a kidney transplant prior to the date
of the actual transplantation. This includes hospitalization for transplant
workup in order to place the patient on a transplant waiting list.

Enter the name of the physician who is supervising the patient’s
renal treatment at the time this form is completed.

47.

Enter the area code and telephone number of the physician who
is supervising the patient’s renal treatment at the time this form is
completed.

48.

Enter the physician’s UPIN assigned by CMS.

32.

Enter the name of the hospital where patient was admitted as an
inpatient in preparation for, or anticipation of, a kidney transplant
prior to the date of the actual transplantation.

33.

Enter the 6-digit Medicare identification number for hospital in Item 32.

34.

Check the appropriate functioning or non-functioning block.

35.

Enter the type of kidney transplant organ donor, Deceased, Living
Related or Living Unrelated, that was provided to the patient.

36.

If transplant is nonfunctioning, enter date patient returned to a
regular course of dialysis. If patient did not stop dialysis post
transplant, enter transplant date.

37.

If applicable, check where patient is receiving dialysis treatment
following transplant rejection. A nursing home or skilled nursing
facility is considered as home setting.

Self-dialysis Training Patients (Medicare Applicants Only)
Normally, Medicare entitlement begins with the third month after
the month a patient begins a regular course of dialysis treatment.
This 3-month qualifying period may be waived if a patient begins a
self-dialysis training program in a Medicare approved training
facility and is expected to self-dialyze after the completion of the
training program. Please complete items 38-43 if the patient has
entered into a self-dialysis training program. Items 38-43 must be
completed if the patient is applying for a Medicare waiver of the
3-month qualifying period for dialysis benefits based on
participation in a self-care dialysis training program.
38.

Enter the name of the provider furnishing self-care dialysis training.

39.

Enter the 6-digit Medicare identification number for the training
provider in Item 38.

40.

Enter the date self-dialysis training began.

41.

Check the appropriate block which describes the type of self-care
dialysis training the patient began. If the patient trained for
hemodialysis, enter whether the training was to perform dialysis in
the home setting or in the facility (in center). If the patient trained
for IPD (Intermittent Peritoneal Dialysis), report as Other.

A system of physician identifiers is mandated by Section 9202 of
the Consolidated Omnibus Budget Reconciliation Act of 1985. It
requires a unique identifier for each physician who provides
services for which Medicare payment is made. An identifier is
assigned to each physician regardless of his or her practice
configuration. The UPIN is established in a national Registry of
Medicare Physician Identification and Eligibility Records (MPIER).
Transamerica Occidental Life Insurance Company is the Registry
Carrier that establishes and maintains the national registry of
physicians receiving Part B Medicare payment. Its address is:
UPIN Registry, Transamerica Occidental Life, P.O. Box 2575,
Los Angeles, CA 90051-0575.
49.

To be signed by the physician supervising the patient’s kidney
treatment. Signature of physician identified in Item 46. A stamped
signature is unacceptable.

50.

Enter date physician signed this form.

51.

To be signed by the physician who is currently following the patient. If
the patient had decided initially not to file an application for Medicare, the
physician will be re-certifying that the patient is end stage renal, based
on the same medical evidence, by signing the copy of the CMS-2728
that was originally submitted and returned to the provider. If you do not
have a copy of the original CMS-2728 on file, complete a new form.

52.

The date physician re-certified and signed the form.

53.

This remarks section may be used for any necessary comments
by either the physician, patient, ESRD Network or social security
field office.

54.

The patient’s signature authorizing the release of information to
the Department of Health and Human Services must be secured
here. If the patient is unable to sign the form, it should be
signed by a relative, a person assuming responsibility for the
patient or by a survivor.

55.

The date patient signed form.

NOTICE
This form is to be completed for all End Stage Renal Disease patients beginning xxxxx xx, xxxx
regardless of when the patient started dialysis or received a kidney transplant. Prior blank versions
of this form should be destroyed. Old versions of the CMS-2728 will not be accepted by the Social
Security Administration or the ESRD Network Organizations after xxxxx xx, xxxx.

FORM CMS-2728-U3 (03/06)