Crosswalk

Revisions to Form CMS-2746-U2; OMB 0938-0448; ESRD DEATH NOTIFICATION
END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM
Issue # Section

Change

Reason for Change

Burden Affect

Deleted “Medicare Claim
Number”. Changed to
“Medicare Beneficiary
Identifier or Social
Security Number”
Added “Unknown” as an
option for place of death

Agency has discontinued
the use of the Social
Security number-based
Medicare ID

N/A

Place of death maybe
unknown to providers at
time of completion of form

N/A

Required verbiage for PRA
Disclosure Statement

N/A

The SSN is important to
use as an identifier for
those patients that do not
have a Medicare
Beneficiary Identifier. Not
all patients will have
Medicare.

N/A

1

#4

2

#6

2

PRA Disclosure
Statement

Added “****CMS

#4

Edited “Enter the patient’s
Medicare Beneficiary
Identifier as it appears on
his/her Medicare Card. If
the patient has not been
assigned a Medicare
Beneficiary Identifier,
enter the Social Security
Number as it appears
his/her Social Security
Card. Only enter the
Social Security Number if
the patient does not have a
Medicare Beneficiary
Identifier.

3

Disclosure**** Please
note that any
correspondence not
pertaining to the
information collection
burden approved under
the associated OMB
control number listed
on this form will not be
reviewed, forwarded, or
retained. If you have
questions or concerns
regarding where to
submit your documents,
please contact the
ESRD Network in your
region.

Issue
4

Section

Change

Reason

Burden

Distribution of
Copies

Changed “Mail the
original (GREEN) copy to
the ESRD network.
Retain the facility
(WHITE) copy at your
facility to “If you are
unable to complete this
form in the approved
CMS electronic system,
forward a hard copy to the
ESRD Network in your
region.

Earlier instructions referred
to the triplicate copy. Form
is no longer a triplicate

N/A

Added “The form CMS2746 can be downloaded
from CMS.gov”