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Revisions to Form CMS-2728-U3; OMB 0938-0046; END STAGE RENAL DISEASE MEDICAL
EVIDENCE REPORT MEDICARE ENTITLEMENT AND/OR PATIENT REGISTRATION
Issue # Section

Change

Reason for Change

Burden Affect

Deleted “Medicare Claim
Number”. Changed to
“Medicare Beneficiary
Identifier or Social Security
Number”
Change “DVA” to “VA

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

N/A

VA is the more
commonly known
acronym for the
Department of Veterans
Affairs
Better define reasons for
patient refusal of
information on the
transplant process

N/A

ICD-10-CM codes became
effective October 1, 2015.

N/A

1

A.

2

A.

3

B

Added “Patient declined
information, Patient has not
been assessed, Patient is not
eligible medically, Other

4

Updated ICD-9-CM codes
to ICD-10-CM codes

5

List of Primary
Causes of Renal
Disease
Instructions

Added “the National
Provider Identifier (NPI)”

Physicians may have a
UPIN or a NPI

N/A

6

Instructions

Edited “If the patient is
covered by Medicare, enter
his/her Medicare
Beneficiary Identifier as it
appears on his/her Medicare
card. If the patient has not
yet 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.”

The 2728 form is used for
both entitlement and
ESRD patient registration.
The SSN is important to
use as an identifier for
those patients that are
applying for entitlement
and do not yet have a
Medicare Beneficiary
Identifier. Not all patients
will have Medicare at the
time they are registering.

N/A

N/A

Revisions to Form CMS-2728-U3; OMB 0938-0046; END STAGE RENAL DISEASE MEDICAL
EVIDENCE REPORT MEDICARE ENTITLEMENT AND/OR PATIENT REGISTRATION
Issue

Section

Change

Reason

Burden Affect

7

Distribution of
Copies

Added “To the Applicant:
Forward the hard copy of this
form with original signatures
to the Social Security office
servicing the claim. To the
Dialysis Facility: Complete
the form in Crown Web or
retain a copy in the patient’s
medical records file.

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

N/A

8

PRA Disclosure
Statement

Added “****CMS
Disclosure**** Please note
that any correspondence not
pertaining to the
information collection
burden approved under the
associated OMB control

Required verbiage for
PRA Disclosure
Statement

N/A

Updated verbiage to
reflect the most recent
standards established by
OMB and used by the
Census Bureau

N/A

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.
9

Instructions

Added “The 1997 OMB
standards permit the
reporting of more than
one race. An individual’s
response to the race
question is based upon
self-identification.”
Updated the racial
categories to reflect
current standards.
Updated the ethnicity
concepts to reflect current
standards.