CMS-2744B End Stage Renal Disease Medical Information System ESRD

Form Approved
OMB No. 0938-0447

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

FOR THE PERIOD

END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM
ESRD FACILITY SURVEY (TRANSPLANT CENTERS ONLY)

KIDNEY TRANSPLANTS PERFORMED
PATIENTS TRANSPLANTED
AND DONOR TYPE

TO BE COMPLETED BY
KIDNEY TRANSPLANT CENTERS ONLY
Eligibility Status of Patients
Transplanted at this Facility
During the Survey Period

Patients
who
received
transplant
at this
facility

Currently
enrolled
in
Medicare

Medicare
Non-Medicare
applicaU.S. Res.
tion
Other
pending

43

42

44

45

Patients Awaiting
Transplant

Transplant Procedures Performed
at This Facility
Living
Related
Donor

47

Living
Total
Unrelated Deceased Fields 47
Donor
Donor
thru 49

48

49

46

Dialysis

50

51

Nondialysis

52

REMARKS/COMMENTS

COMPLETED BY (Name)

DATE

TITLE

TELEPHONE NO.

This report is required by law (42 USC 426; 42 CFR 405.2133). Individually identifiable patient information will not be disclosed except as provided for in the Privacy Act of 1974
(5 USC 5520; 45 CFR, Part 5a).
Form CMS-2744B (02/04)