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)