The primary purpose of the END STAGE
RENAL DISEASE MEDICAL EVIDENCE REPORT MEDICARE ENTITLEMENT AND/OR
PATIENT REGISTRATION is to determine if an individual is entitled
to Medicare under the End Stage Renal Disease provisions of the
law. This form SHOULD NOT be completed for those patients who are
in acute renal failure. Completion of the form is voluntary, but
failure to do so may result in denial of Medicare
benefits.
US Code:
42
USC 289c Name of Law: Research on public health emergencies
US Code: 42
USC 426-1 Name of Law: SPECIAL PROVISIONS RELATING TO COVERAGE
UNDER MEDICARE PROGRAM FOR END STAGE RENAL DISEASE
US Code: 42
USC 241a Name of Law: Research and investigations generally
There is a change in total
estimated burden hours of 69,000 (172,500 estimated hours- 103,500
previously estimated hours) due to an increase in the time to
complete the CMS-2728 forms by 30 minutes and a decrease in
submission of CMS-2728 forms by 5,929 submissions (138,000
previously estimated submissions-132,071 submissions).
On behalf of this Federal agency, I certify that
the collection of information encompassed by this request complies
with 5 CFR 1320.9 and the related provisions of 5 CFR
1320.8(b)(3).
The following is a summary of the topics, regarding
the proposed collection of information, that the certification
covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a
benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control
number;
If you are unable to certify compliance with any of
these provisions, identify the item by leaving the box unchecked
and explain the reason in the Supporting Statement.
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....
Non-substantive change memo (CMS-2728).docx
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....