End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration and Supporting Regulations in 42 CFR, 405.2133; PL 95-292; CFR Parts....

End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration (CMS-2728)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0046 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-2728 End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration and Supporting Regulations in 42 CFR, 405.2133; PL 95-292; CFR Parts.... Form
CMS-2728 ESRD Medical Evidence Report CMS-2728 instrument 508 clean 3-9-23.docx Form
CMS-2728 ESRD Medical Evidence Report CMS2728i508 comment revisions clean v2.docx Form
CMS-2728 instrument 508 redline 3-9-23.docx CMS-2728 instrument - redline IC Document
CMS-2728 instrument 508 redline 3-9-23.docx CMS-2728 instrument - redline IC Document
CMS-2728 Crosswalk 508 redline 3-9-23.docx Crosswalk redline IC Document
CMS-2728 Crosswalk 508 redline 3-9-23.docx Crosswalk redline IC Document
CMS-2728 Crosswalk 508 3-9-23 clean.docx Crosswalk IC Document
CMS-2728 Crosswalk 508 3-9-23 clean.docx Crosswalk IC Document

Information Collection (IC) Details

IC Title:	End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration and Supporting Regulations in 42 CFR, 405.2133; PL 95-292; CFR Parts....	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 405.2133

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-2728	ESRD Medical Evidence Report	CMS2728i508 comment revisions clean v2.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,828	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	138,000	0	138,000
Annual IC Time Burden (Hours)	172,500	69,000	103,500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.