End Stage Renal Disease Death Notification, P.L. 95-292; 42 CFR 405.2133; 45 CFR 5,5b; 20 CFR Parts 401, 422E

End Stage Renal Disease Death Notification (CMS-2746)

Documents and Forms

Document Name Document Type
Form CMS-2746 End Stage Renal Disease Death Notification, P.L. 95-292; 42 CFR 405.2133; 45 CFR 5,5b; 20 CFR Parts 401, 422E Form
CMS-2746 ESRD Death Notification Form CMSForm2746ESRD revised.docx Form
CMS-2746 ESRD Death Notification Form CMSForm2746ESRD revised clean_V3.docx Form
2746Crosswalk508.docx.pdf Crosswalk IC Document
2746Crosswalk508.docx.pdf Crosswalk IC Document
CMSForm2746ESRD redline.docx Redline IC Document
CMSForm2746ESRD redline.docx redline IC Document
CMSForm2746ESRD revised redline_V3 2-29-24.docx redline IC Document

Information Collection (IC) Details

IC Title:	End Stage Renal Disease Death Notification, P.L. 95-292; 42 CFR 405.2133; 45 CFR 5,5b; 20 CFR Parts 401, 422E	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 401.. 20 CFR 422.Subpart E 45 CFR 5.5b 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-2746	ESRD Death Notification Form	CMSForm2746ESRD revised clean_V3.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,726	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	101,491	9,468	92,023
Annual IC Time Burden (Hours)	50,746	4,734	46,012
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	2746Crosswalk508.docx.pdf	09/27/2023
redline	CMSForm2746ESRD redline.docx	02/29/2024
redline	CMSForm2746ESRD revised redline_V3 2-29-24.docx	02/29/2024

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