Form CMS-2728 ESRD Medical Evidence Report

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE AND MEDICAID SERVICES OMB No. 0938-0046

END STAGE RENAL DISEASE MEDICAL EVIDENCE REPORT
MEDICARE ENTITLEMENT AND/OR PATIENT REGISTRATION
A. COMPLETE FOR ALL ESRD PATIENTS Check One: Initial ☐ Re-entitlement ☐ Supplemental ☐
1. Name (Last, First, Middle Initial)

2. Medicare Number (if available)

3. Social Security Number

5. Patient Mailing Address (Include City, State and Zip)

8. Sex at Birth
☐ Male ☐ Female
Pronouns:
☐ He/Him
☐ She/Her
☐ They/Them
☐ A combination of the
above

4. Date of Birth (mm/dd/yyyy)

6. Phone Number (including area
code)

9. Gender Identity
☐Cisgender man ☐Cisgender woman
☐Genderqueer/gender nonconforming neither exclusively male nor
female ☐Transgender man/trans man ☐Transgender
woman/trans woman

7. Alternate Phone Number
(including area code)
10. Ethnicity*
☐ Not Hispanic or Latino☐
Hispanic or Latino
* See Instructions
11. Country/Area of Origin or
Ancestry

☐Additional gender category
(or other); please specify: _______________

12. Race* ☐ Multiracial (Check all that apply)
☐ American Indian/Native Alaskan
Asian
☐ Asian Indian
☐ Japanese
☐ Chinese
☐ Korean
☐ Filipino
☐ Vietnamese
☐ Guamanian or Chamorro
☐ Other Asian
☐ Black or African American
☐ Middle Eastern North Africa
Native Hawaiian and Pacific Islander
☐ Native Hawaiian
☐ Other Pacific Islander
☐ Samoan
☐ White
☐ Other if unable to identify with any of these five race categories

13. Is patient applying for
ESRD Medicare coverage?
☐ Yes
☐ No

Print Name of Enrolled/Principal Tribe______________________ *See Instructions
14. Current Medical Coverage (Check all that apply)
☐ Employer Group Health Insurance ☐ Medicare
☐ Medicaid ☐ Veterans Administration
☐ Medicare Advantage ☐ Other ☐ None
18. Occupation Status (6 months
prior and current status)
Prior Current
☐ ☐ Unemployed
☐ ☐ Employed Full Time
☐ ☐ Employed Part Time
☐ ☐ Homemaker
☐ ☐ Retired due to
Age/Preference
☐ ☐ Retired (Disability)
☐ ☐ Medical Leave of
Absence
☐ ☐ Student
☐ ☐ Volunteer

15. Height
Inches______
OR
Centimeters
______

19. Co-Morbid Conditions (Check all
that apply currently and/or during
last 10 years)
a. ☐ Congestive heart failure
b. ☐ Atherosclerotic heart disease
ASHD
c. ☐ Other cardiac disease
d. ☐ Cerebrovascular disease, CVA,
TIA*
e. ☐ Peripheral vascular disease*
f. ☐ History of hypertension
g. ☐ Amputation
h. ☐ Diabetes, ☐ currently on insulin
☐ currently use other injectable ☐ on
oral medications
☐ without medications
i. ☐ Diabetic retinopathy
j. ☐ Chronic obstructive pulmonary
disease

16. Dry Weight
Pounds_______
OR
Kilograms______

17. Primary Cause of Renal
Failure (Use code at end of
form)

dd. ☐ Major Depressive Disorder
ee. ☐ Myasthenia Gravis
ff. ☐ Guillain-Barre Syndrome
gg. ☐ Inflammatory Neuropathy
hh. ☐ Parkinson’s Disease
ii. ☐ Huntington’s Disease
jj. ☐ Seizure Disorders and Convulsions
kk.☐ Interstitial lung disease
ll. ☐ Partial- thickness Dermis Wounds
mm. ☐ Complications of specified implanted
device or graft
nn. ☐ Artificial Openings for feeding or
Elimination
Consider for Pediatric Patients
oo. ☐ Chronic lung disease (including
dependency on CPAP and ventilators)
pp. ☐ Vision impairment
qq. ☐ Feeding tube dependence

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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE AND MEDICAID SERVICES OMB No. 0938-0046

END STAGE RENAL DISEASE MEDICAL EVIDENCE REPORT
MEDICARE ENTITLEMENT AND/OR PATIENT REGISTRATION
k. ☐ Tobacco use (current smoker)
l. ☐ Malignant neoplasm, Cancer
m. ☐ Toxic nephropathy
n. ☐ Alcohol dependence
o. ☐ Drug dependence*
p. ☐ Inability to ambulate*
q. ☐ Inability to transfer*
r. ☐ Needs assistance with daily
activities*
s. ☐ Alternate housing arrangement:
☐ Assisted Living ☐ Nursing Home
☐ Other Institution
t. ☐ Non-renal congenital abnormality
u. ☐ None (no comorbidities)
v. ☐ Protein Calorie Malnutrition
w. ☐ Morbid Obesity
x. ☐ Endocrine Metabolic Disorders
y. ☐ Intestinal Obstruction/Perforation
z. ☐ Chronic Pancreatitis
aa. ☐ Inflammatory Bowel Disease
bb. ☐ Bone/Joint/Muscle
Infections/Necrosis
cc. ☐ Dementia

rr .☐ Failure to thrive/feeding disorders
ss.☐ Congenital anomalies requiring
subspecialty intervention (cardiac, orthopedic,
colorectal)
tt. ☐ Congenital bladder/urinary tract
anomalies
uu. ☐ Non-kidney solid organ
vv. ☐ Stem cell transplant
ww. ☐ Neurocognitive impairment
xx. ☐ Global developmental delay
yy. ☐ Cerebral palsy
zz. ☐ Seizure disorder
* See instructions

20. Prior to ESRD therapy:
a. Did patient receive exogenous erythropoietin or equivalent? ☐Yes ☐No ☐Unknown If Yes, answer: ☐<6 months ☐6-12
months ☐>12 months
b. Was patient under routine care of a nephrologist? ☐Yes ☐No ☐Unknown If Yes, answer: ☐<6 months ☐6-12 months ☐
>12 months
c. Was patient under routine care of kidney dietitian? ☐Yes ☐No ☐Unknown If Yes, answer: ☐<6 months ☐6-12 months ☐
>12 months
d. What access was used on first outpatient dialysis: ☐AVF ☐Graft ☐ PD Catheter ☐Central Venous Catheter ☐Other If not
AVF, then: Is maturing AVF present? ☐Yes ☐No Is graft present? ☐Yes ☐No Was one lumen of the Central Venous
Catheter used and one needle placed in a AVF or graft? ☐ Yes ☐ No Is PD catheter present? ☐Yes ☐No
e. Was patient diagnosed with an acute kidney injury in the last 12 months? ☐Yes ☐No ☐Unknown If Yes, was dialysis
required? ☐ Yes ☐ No
f. Does the patient indicate they received and understood options for a home dialysis modality? ☐ Yes ☐ No
g. Does the patient indicate they received and understood options for a kidney transplant? ☐ Yes ☐ No For Living donor
transplant ☐ Yes ☐ No
h. Does the patient indicate they received and understood the option of not starting dialysis at all, also called active medical
management without dialysis? ☐ Yes ☐ No
21. Laboratory Values Within 45 Days Prior to the Most Recent ESRD Episode. If not available within 30 days of admission to the
dialysis facility for ESRD treatment, admission laboratory values may be used. (HbA1c and LDL within 1 Year of Most Recent
ESRD Episode). ☐ Prior Lab Values ☐ Admission Lab Values
Lab Test
Value
Date
Lab Test
Value
Date
(a) Serum Albumin
g/dl
(b) Serum Albumin
Lower Limit
(c) Lab Method
Used (BCG/BCP)
(d) Serum
Creatinine mg/dl

____.____

(e) Hemoglobin g/dl

____.____

____.____

(f) HbA1c

____.____

(g) LDL

____.____

(h) Cystatin C

____.____

____.____

22. Does the patient have living will or Medical/Physician order for life sustaining treatment ☐ Yes ☐ No
23. Are you currently concerned about where you will live over the next 90 days ☐ Yes ☐ No
24. Do you have caregiver support to assist with your daily care ☐Yes ☐ No With home dialysis/kidney transplant ☐ Yes ☐ No
Does the caregiver live with you ☐ Yes ☐ No
25. Do you have access to reliable transportation ☐ Yes ☐ No
26. Do you understand health literature in English ☐ Yes ☐ No Do you need a different way other than written documents to
learn about your health ☐ Yes ☐ No Do you need a translator to understand health information ☐ Yes ☐ No

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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE AND MEDICAID SERVICES OMB No. 0938-0046

END STAGE RENAL DISEASE MEDICAL EVIDENCE REPORT
MEDICARE ENTITLEMENT AND/OR PATIENT REGISTRATION
27. Do you find it hard to pay for the very basics like housing, medical care, electricity, and heating ☐ Yes ☐ No
28. Within the past 12 months, has the food you bought not lasted and you didn't have money to get more? ☐ Yes ☐ No
29. Has anyone, including family and friends, threatened you with harm or physically hurt you in the last 12 months? ☐ Yes ☐No
B. COMPLETE FOR ALL ESRD PATIENTS IN DIALYSIS TREATMENT
30. Name of Dialysis Facility

31. CMS Certification Number (CCN) (for item 30)

32. Primary Dialysis Setting
☐ Home ☐ In-center ☐ SNF/LTC*
*See Instructions

33. Primary Type of Dialysis
☐ Hemodialysis (Sessions per Week___/Minutes per Session___)
☐ CAPD ☐ CCPD ☐ Other

34. Date Regular Chronic Dialysis Began (mm/dd/yyyy)
**See Instructions

35. Date Patient Started Chronic Dialysis at Current Facility
(mm/dd/yyyy) *

36. Does the patient
understand kidney
transplant options at the
time of admission? *
☐ Yes ☐ No ☐ N/A (if
patient answered yes to
question 20(g)
*See Instructions

*See Instructions
37. If patient NOT informed of transplant options (or does not
understand transplant options) please check all that apply:
☐ Patient found information ☐ Patient declined information
overwhelming*
☐ Cognitive Impairment* ☐ Patient has not been assessed at this
time
☐ Patient has an absolute contraindication* ☐ Other

38. Has the patient been
connected to a transplant
center with a referral?*
☐ Yes ☐ No
Date of referral
(mm/dd/yyyy)
Name of transplant center

*See Instructions
39. Does the patient understand home dialysis options at the time of
admission? *
☐ Yes ☐ No ☐ N/A (if patient answered yes to question 20(f)
*See Instructions

*See Instructions
40. If patient NOT informed of home dialysis options
(or does not understand home dialysis options) please
check all that apply:
☐ Patient found information ☐ Patient declined
information overwhelming*
☐ Cognitive Impairment* ☐ Patient has not been
assessed at this time
☐ Patient has an absolute contraindication* ☐ Other
*See Instructions

C. COMPLETE FOR ALL KIDNEY TRANSPLANT PATIENTS
41. Date of Transplant (mm/dd/yyyy)

42. Name of Transplant Hospital

43. CMS Certification Number (CCN) (for Item
42)

Date patient was admitted as an inpatient to a hospital in preparation for, or anticipation of, a kidney transplant prior to the date of
actual transplantation.
44. Enter Date (mm/dd/yyyy)

45. Name of Preparation Hospital

47. Current Status of Transplant (if functioning, skip
items 45 and 46)
☐ Functioning ☐ Non-Functioning
49. If Non-Functioning, Date of Return to Regular
Dialysis (mm/dd/yyyy)

46. CMS Certification Number (CCN) (for Item
45)

48. Type of Transplant:
☐ Deceased Donor ☐ Living Related ☐ Living Unrelated ☐Multiorgan ☐ Paired Exchange
50. Current Dialysis Setting
☐ Home ☐ In-center ☐ SNF/LTC* ☐ Transitional Care Unit*
*See Instructions

D. COMPLETE FOR ALL ESRD SELF-DIALYSIS TRAINING PATIENTS (MEDICARE APPLICANTS ONLY)
51Name of Training Provider

52. CMS Certification Number (CCN) of Training Provider (for Item
51)

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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE AND MEDICAID SERVICES OMB No. 0938-0046

END STAGE RENAL DISEASE MEDICAL EVIDENCE REPORT
MEDICARE ENTITLEMENT AND/OR PATIENT REGISTRATION
53. Date Training Began (mm/dd/yyyy)

54. Type of Training
Hemodialysis (select one) a. ☐ Home b. ☐ In-center
☐ CAPD ☐ CCPD ☐ Other
56. Date When Patient Completed, or is Expected to Complete,
Training
(mm/dd/yyyy)

55. This Patient is Expected to Complete (or has
completed) Training and will Self-dialyze on a Regular
Basis.
☐ Yes ☐ No
I certify that the above self-dialysis training information is correct and is based on consideration of all pertinent
medical, psychological, and sociological factors as reflected in records kept by this training facility.
57. Printed Name and Signature of Physician personally familiar with the patient’s training
58. NPI of Physician in Item 47
a.) Printed Name

b.) Signature

c.) Date
(mm/dd/yyyy)

E. PHYSICIAN IDENTIFICATION
59. Attending Physician (Print)

60. Physician’s Phone No. (include
Area Code)

61. NPI of Physician

PHYSICIAN ATTESTATION
I certify, under penalty of perjury, that the information on this form is correct to the best of my knowledge and belief.
Based on diagnostic tests and laboratory findings, I further certify that this patient has reached the stage of renal
impairment that appears irreversible and permanent and requires a regular course of dialysis or kidney transplant to
maintain life. I understand that this information is intended for use in establishing the patient’s entitlement to
Medicare benefits and that any falsification, misrepresentation, or concealment of essential information may subject
me to fine, imprisonment, civil penalty, or other civil sanctions under applicable Federal laws.
62. Attending Physician’s Signature of Attestation (Same as Item 61)
63. Date (mm/dd/yyyy)

64. Physician Recertification Signature

65. Date (mm/dd/yyyy)

66. Remarks:

F. OBTAIN SIGNATURE FROM PATIENT
I hereby authorize any physician, hospital, agency, or other organization to disclose any medical records or other
information about my medical condition to the Department of Health and Human Services for purposes of reviewing my
application for Medicare entitlement under the Social Security Act and/or for scientific research.
67. Signature of Patient (Signature by mark must be witnessed.)
68. Date (mm/dd/yyyy)

If patient unable to sign/mark check below:
☐ Lost to Follow-up ☐ Moved out of the United States and territories ☐ Expired Date (mm/dd/yyyy)
G. PRIVACY STATEMENT
The collection of this information is authorized by Section 226A of the Social Security Act. The information provided will be used to determine if an individual is entitled to
Medicare under the End Stage Renal Disease provisions of the law. The information will be maintained in system No. 09 -700520, “End Stage Renal Disease Program
Management and Medical Information System (ESRD PMMIS)”, published in the Federal Register, Vol. 67, No. 116, June 17, 2002, pages 41244-41250 or as updated and
republished. Collection of your Social Security number is authorized by Executive Order 9397.
Furnishing the information on this form is voluntary, but failure to do so may result in denial of Medicare benefits. Information from the ESRD PMMIS may be given to a
congressional office in response to an inquiry from the congressional office made at the request of the individual; an individual or organization for research, demonstration,
evaluation, or epidemiologic project related to the prevention of disease or disability, or the restoration or maintenance of health. Additional disclosures may be found in the
Federal Register notice cited above. You should be aware that P.L.100-503, the Computer Matching and Privacy Protection Act of 1988, permits the government to verify
information by way of computer matches.

LIST OF PRIMARY CAUSES OF RENAL DISEASE
Item 17. Primary Cause of Renal Failure should be completed by the attending physician from the list below. Enter the ICD-10-CM
code to indicate the primary cause of end stage renal disease. If there are several probable causes of renal failure, choose one as
primary. An ICD-10-CM code is effective as of February 1 2022.
kidney disease
DIABETES
E10.29
Type 1 diabetes mellitus with other diabetic
kidney complication
E10.22
Type 1 diabetes mellitus with diabetic chronic

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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE AND MEDICAID SERVICES OMB No. 0938-0046
E11.21
E11.22
E11.29

Type 2 diabetes mellitus with diabetic
nephropathy
Type 2 diabetes mellitus with diabetic chronic
kidney disease
Type 2 diabetes mellitus with other diabetic
kidney complication

GLOMERULONEPHRITIS
N00.8
Acute nephritic syndrome with other
morphologic changes
N01.9
Rapidly progressive nephritic syndrome with
unspecified morphologic changes
N02.8
Recurrent and persistent hematuria with other
morphologic changes
N03.0
Chronic nephritic syndrome with minor
glomerular abnormality
N03.1
Chronic nephritic syndrome with focal and
segmental glomerular lesions
N03.2
Chronic nephritic syndrome with diffuse
membranous glomerulonephritis
N03.3
Chronic nephritic syndrome with diffuse
mesangial proliferative glomerulonephritis
N03.4
Chronic nephritic syndrome with diffuse
endocapillary proliferative glomerulonephritis
N03.5
Chronic nephritic syndrome with diffuse
mesangiocapillary glomerulonephritis
N03.6
Chronic nephritic syndrome with dense deposit
disease
N03.7
Chronic nephritic syndrome with diffuse
crescentic glomerulonephritis
N03.8
Chronic nephritic syndrome with other
morphologic changes
N03.9
Chronic nephritic syndrome with unspecified
morphologic changes
N04.0
Nephrotic syndrome with minor glomerular
abnormality
N04.1
Nephrotic syndrome with focal and segmental
glomerular lesions
N04.2
Nephrotic syndrome with diffuse membranous
glomerulonephritis
N04.3
Nephrotic syndrome with diffuse mesangial
proliferative glomerulonephritis
N04.4
Nephrotic syndrome with diffuse endocapillary
proliferative glomerulonephritis
N04.5
Nephrotic syndrome with diffuse
mesangiocapillary glomerulonephritis
N04.6
Nephrotic syndrome with dense
deposit disease
N04.7
Nephrotic syndrome with diffuse
crescentic glomerulonephritis
N04.8
Nephrotic syndrome with other
morphologic changes
N04.9
Nephrotic syndrome with
unspecified morphologic
changes
N05.9
Unspecified nephritic syndrome with
unspecified morphologic changes
N07.0
Hereditary nephropathy, not elsewhere
classified with minor glomerular abnormality
INTERSTITIAL NEPHRITIS/PYELONEPHRITIS
N10
Acute tubulo-interstitial nephritis

N11.9
N13.70
N13.8

Chronic tubulo-interstitial nephritis,
unspecified
Vesicoureteral-reflux, unspecified
Other obstructive and reflux uropathy 2

TRANSPLANT COMPLICATIONS
T86.00
Unspecified complication of bone marrow
transplant
T86.10
Unspecified complication of kidney transplant
T86.20
Unspecified complication of heart transplant
T86.40
Unspecified complication of liver transplant
T86.819 Unspecified complication of lung transplant
T86.859 Unspecified complication of intestine
transplant
T86.899 Unspecified complication of other
transplanted tissue

HYPERTENSION/LARGE VESSEL DISEASE
I12.0

I12.9

I15.0
I15.8
I75.81

Hypertensive chronic kidney disease with
stage 5 chronic kidney disease or end stage
renal disease
Hypertensive chronic kidney disease with
stage 1through stage 4 chronic kidney
disease, or unspecified chronic kidney
disease
Renovascular hypertension
Other secondary hypertension
Atheroembolism of kidney

CYSTIC/HEREDITARY/CONGENITAL/OTHER
DISEASES
E72.04
Cystinosis
E72.53
Hyperoxaluria
E75.21
Fabry (-Anderson) disease
N07.8
Hereditary nephropathy, not elsewhere
classified with other morphologic lesions
N31.9
Neuromuscular dysfunction of bladder,
unspecified
Q56.0
Hermaphroditism, not elsewhere classified
Q60.2
Renal agenesis, unspecified
Q61.19
Other polycystic kidney, infantile type
Q61.2
Polycystic kidney, adult type
Q61.4
Renal dysplasia
Q61.5
Medullary cystic kidney
Q61.8
Other cystic kidney diseases
Q62.11
Congenital occlusion of ureteropelvic junction
Q62.12
Congenital occlusion of ureterovesical orifice
Q63.8
Other specified congenital malformation of
kidney
Q64.2
Congenital posterior urethral valves
Q79.4
Prune belly syndrome
Q85.1
Tuberous sclerosis
Q86.8
Other congenital malformation syndromes
due to known exogenous causes
Q87.1
Congenital malformation syndromes
predominantly associated with short stature
Q87.81
Alport syndrome

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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE AND MEDICAID SERVICES OMB No. 0938-0046
NEOPLASMS/TUMORS
C64.9
Malignant neoplasm of unspecified kidney,
except renal pelvis
C80.1
Malignant (primary) neoplasm, unspecified
C85.93
Non-Hodgkin lymphoma, unspecified, intraabdominal lymph nodes
C88.2
Heavy chain disease
C90.00
Multiple myeloma not having achieved
remission
D30.9
Benign neoplasm of urinary organ,
unspecified
D41.00
Neoplasm of uncertain behavior of
unspecified kidney
D41.9
Neoplasm of uncertain behavior of
unspecified urinary organ
E85.9
Amyloidosis, unspecified
N05.8
Unspecified nephritic syndrome with
other morphologic changes
DISORDERS OF MINERAL METABOLISM
E83.52
Hypercalcemia
SECONDARY GLOMERULONEPHRITIS/VASCULITIS
D59.3
Hemolytic-uremic syndrome
D69.0
Allergic purpura
I77.89
Other specified disorders of arteries and
arterioles
M31.0
Hypersensitivity angiitis
M31.1
Thrombotic microangiopathy
M31.31
Wegener’s granulomatosis with renal
involvement
M31.7
Microscopic polyangiitis
M32.0
Drug-induced systemic lupus erythematosus
M32.10
Systemic lupus erythematosus, organ or
system involvement unspecified
M32.14
Glomerular disease in systemic lupus
erythematosus
M32.15
Tubulo-interstitial nephropathy in systemic
lupus erythematosus
M34.89
Other systemic sclerosis

GENITOURINARY SYSTEM
A18.10
Tuberculosis of genitourinary system,
unspecified
N28.9
Disorder of kidney and ureter,
unspecified

ACUTE KIDNEY FAILURE
N17.0
Acute kidney failure with tubular
necrosis
N17.1
Acute kidney failure with acute cortical
necrosis
N17.9
Acute kidney failure, unspecified

MISCELLANEOUS CONDITIONS
B20
Human immunodeficiency virus [HIV]
disease
D57.1
Sickle-cell disease without crisis
D57.3
Sickle cell trait
I50.9
Heart failure, unspecified
K76.7
Hepatorenal syndrome
M10.30
Gout due to renal impairment,
unspecified site
N14.0
Analgesic nephropathy
N14.1
Nephropathy induced by other drugs,
medicaments and biological
substances
N14.3
Nephropathy induced by heavy metals
N20.0
Calculus of kidney
N25.89
Other disorders resulting from
impaired renal tubular function
N26.9
Renal sclerosis, unspecified
N28.0
Ischemia and infarction of kidney
N28.89
Other specified disorders of kidney
and ureter
O90.4
Postpartum acute kidney failure
S37.009A Unspecified injury of unspecified
kidney, initial encounter
Z90.5
Acquired Absence of Kidney
U07.1
COVID19

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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE AND MEDICAID SERVICES OMB No. 0938-0046

INSTRUCTIONS FOR COMPLETION OF END STAGE RENAL DISEASE
MEDICAL EVIDENCE REPORT MEDICARE ENTITLEMENT AND/OR PATIENT
REGISTRATION
Submission of CMS-2728 Form:
•
To the Applicant: Forward a hard, fax, or email copy of this form with signatures to the Social Security office in your
area.
•
To the Dialysis Facility: Complete this form in the ESRD Quality Reporting System (EQRS) and print. Provide the
applicant with a copy of the form and/or assist them in submitting the form to the appropriate Social Security office.

For whom should this form be completed:
This form SHOULD NOT be completed for those
patients who are in acute renal failure. Acute renal
failure is a condition in which kidney function can be
expected to recover after a short period of dialysis,
i.e., several weeks or months.
This form MUST BE completed within 45 days for ALL
patients beginning any of the following:
Check the appropriate block that identifies the reason
for submission of this form.
Initial
For all patients who initially receive a kidney
transplant instead of a course of dialysis.
For patients for whom a regular course of dialysis
has been prescribed by a physician because they
have reached that stage of renal impairment that a
kidney transplant or regular course of dialysis is
necessary to maintain life. The first date of a regular
course of dialysis is the date this prescription is
implemented whether as an inpatient of a hospital, an
outpatient in a dialysis

center or facility, or a home patient. The form should
be completed for all patients in this category even if
the patient dies within this time period.
Re-entitlement
For beneficiaries who have already been
entitled to ESRD Medicare benefits and
those benefits were terminated because their
coverage stopped 3 years post-transplant but
now are again applying for Medicare ESRD
benefits because they returned to dialysis or
received another kidney transplant.
For beneficiaries who stopped dialysis for more than
12 months, have had their Medicare ESRD benefits
terminated and now returned to dialysis or received a
kidney transplant. These patients will be reapplying
for Medicare ESRD benefits.
Supplemental
Patient has received a transplant or trained for
self-care dialysis within the first 3 months of the first
date of dialysis and initial form was submitted.

All items except as follows: To be completed by the attending physician, head nurse, or social worker involved in this
patient’s treatment of renal disease.
Items: 17, 19-20, 36-40: To be completed by the attending physician.
Item 70 and 72: To be signed by the attending physician or the physician familiar with the patient’s self-care dialysis training
Items 75 and 76: To be signed and dated by the patient.

1.

2.

3.

Enter the patient’s legal name (Last, first, middle
initial). Name should appear exactly the same as
it appears on patient’s social security or
Medicare card.
If the patient is covered by Medicare, enter
his/her/their Medicare Beneficiary Identifier
(Medicare Number) as it appears on his/her/their
Medicare card.
Enter the Social Security Number as it appears
on his/her/their Social Security Card. If the
patient voices concern explain this is
necessary to correctly match the patient so
benefits can be assigned.

4.

Enter patient’s date of birth (2-digit Month,
Day, and 4-digit Year). Example 07/25/1950.

5.

Enter the patient’s mailing address (number and
street or post office box number, city, state, and
ZIP code.)

6.

Enter the patient’s area code and telephone
number.

7.

Enter the patient’s alternate area code and
telephone number, if available for disaster
purposes.

8.

Ask the patient and check the appropriate block to
identify sex at birth and pronouns.

9.

Ask the patient and check the appropriate block
to indicate the gender the patient identifies as.

10. Ask the patient and check the appropriate
block to identify ethnicity. Definitions of the
ethnicity categories for Federal statistics are as
follows:
Not Hispanic or Latino—A person of culture or
origin not described below, regardless of race.
Hispanic or Latino—A person of Cuban,
Mexican, Puerto Rican, South or Central
American, or other Spanish culture or origin

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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
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regardless of race. Please complete Item 11
and provide the country, area of origin, or
ancestry to which the patient claims to belong.

14.

11. Country/Area of origin or ancestry—Complete if
information is available.

Employer Group Health Insurance—Patient
receives medical benefits through an
employee health plan that covers employees,
former employees, or the families of employees
or former employees.

12. Ask the patient and check the appropriate
block(s) to identify race. The 1997 OMB
standards permit the reporting of more than
one race. An individual’s response to the
race question is based upon selfidentification. If a patient identifies as more
than one race then check Multiracial and
check all of the racial categories that
apply.

Medicare—Patient is currently entitled to
Federal Medicare benefits.
Medicaid—Patient is currently receiving State
Medicaid benefits.
Veterans Administration—Patient is
receiving medical care from a Department of
Veterans Affairs facility.

Definitions of the racial categories for
Federal statistics are as follows:

Medicare Advantage—Patient is receiving
medical benefits under a Medicare
Advantage (Medicare Part A and Part B
coverage offered by Medicare-approved
private companies that must follow rules set
by Medicare) organization.

American Indian/Alaska Native—A
person having origins in any of the
original peoples of North and South
America (including Central America) and
who maintains tribal affiliation or
community attachment.

Other Medical Insurance—Patient is receiving
medical benefits under a health insurance plan
that is not Medicare, Medicaid, Department of
Veterans Affairs, Medicare Advantage, nor an
employer group health insurance plan.
Examples of other medical insurance are
Railroad Retirement and CHAMPUS
beneficiaries or that obtains insurance through
the Marketplace.

Asian—A person having origins in any of the
original peoples of the Far East, Southeast Asia,
or the Indian subcontinent including, for example,
Cambodia, China, India, Japan, Korea, Malaysia,
Pakistan, the Philippine Islands, Thailand, and
Vietnam.
Black or African American—A person having
origins in any of the Black racial groups of
Africa.
Middle Eastern or North African – A person
having origins in any of the original peoples of
Lebanese, Iranian, Egyptian, Syrian,
Moroccan and Israeli

None—Patient has no medical insurance plan.
15.

Enter the patient’s most recent recorded
height in inches OR centimeters at time form
is being completed. If entering height in
centimeters, round to the nearest centimeter.
Estimate or use last known height for those
unable to be measured. (Example of inches 62. DO NOT PUT 5’2”) NOTE: For amputee
patients, enter height prior to amputation.

16.

If the patient identifies as American Indian,
Alaska Native, Native Hawaiian, or Other
Pacific Islander complete the name of the
enrolled or principal tribe.

Enter the patient’s most recent recorded dry
weight in pounds OR kilograms at time form is
being completed. If entering weight in
kilograms, round to the nearest kilogram.
NOTE: For amputee patients, enter actual
dry weight without prosthesis.

17.

Check the appropriate yes or no block to
indicate if patient is applying for ESRD
Medicare. Note: Even though a person
may already be entitled to general
Medicare coverage, he/she should
reapply for ESRD Medicare coverage.
Additionally, if the patient has private
insurance beginning dialysis starts the
30-month coordination of benefits
period. If the patient doesn’t accept
Medicare Part B during the 30-month
window, they may lose the ability to
apply until the General Enrollment Period
(GEP) and will likely face gaps in
coverage and a late enrollment penalty.

Primary Cause of Renal Failure should be
determined by the attending physician
using the appropriate ICD-10-CM
code. Enter the ICD-10-CM code from page 4
or 6 of form to indicate the primary cause of end
stage renal disease. If there are several
probable causes of renal failure, choose one as
primary. An ICD-10-CM code is effective as of
February 1, 2022. These are the only acceptable
causes of end stage renal disease.

18.

Check the first box to indicate occupation 6
months prior to renal failure and the second
box to indicate current occupation. Check only
one box for each time period. If patient is
under 6 years of age, leave blank.

19.

This section was broadened to be
more inclusive of pediatric patients. I
and J were intentionally not used in

Native Hawaiian or Other Pacific
Islander—A person having origins in any of
the original peoples of Hawaii, Guam, Samoa,
or other Pacific Islands.
White—A person having origins in any of the
original peoples of Europe.
Other Race—For respondents unable to
identify with any of these five race categories

13.

Check all the blocks that apply to this
patient’s current medical insurance
status.

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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
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the lettering to accommodate
previous system comorbidities and
provide lettering continuity.
To be completed by the attending
physician. Check all co-morbid
conditions that apply.
*Cerebrovascular Disease includes history
of stroke/ cerebrovascular accident (CVA) and
transient ischemic attack (TIA).
*Peripheral Vascular Disease includes
absent foot pulses, prior typical claudication,
amputations for vascular disease, gangrene
and aortic aneurysm.
*Drug dependence means dependent on illicit
drugs.
*Inability to ambulate includes an
impairment(s) that interferes very seriously with
the individual's ability to independently initiate or
sustain ambulation
*Inability to transfer from bed to chair, or chair
to chair, or chair to bed
*Needs assistance with daily activities
including basic physical needs, comprised the
following areas: grooming/personal hygiene,
dressing, toileting/continence, and eating
The section titled “Consider for Pediatric
Patients” should only be used for pediatric
patients.
20. Prior to ESRD therapy, check the appropriate box to
indicate whether the patient
• (a)received Exogenous erythropoietin (EPO) or
equivalent,
• (b)was under the routine care of a nephrologist
• (c) was under the routine care of a kidney
dietitian
• (d)provide vascular access information as to
the type of access used for the majority of
the treatment (Arterio-Venous Fistula
(AVF), graft, peritoneal dialysis (PD)
catheter, or Central Venous Catheter
(including port device) or other type of
access) when the patient first received
outpatient dialysis. If an AVF access was not
used, was a AVF or graft present? Was one
lumen of the Central Venous Catheter used
and one need placed in a AVF or graft?
• (e)Indicate if the patient experienced acute
renal failure (the sudden inability for the
kidney to filter waste products which may
resolve or evolve to ESRD) and if dialysis
was required.
• (f)Indicate the patient received and understood
options for a home dialysis modality.
• (g)Indicate if the patient received and
understood options for a kidney transplant.
For living donor transplant.
• (h) Indicate if the patient received and
understood the option of not starting dialysis
at all, also called active medical
management without dialysis.

NOTE: For those patients re-entering the
Medicare program after benefits were terminated,
items in question 21 should contain initial
laboratory values within 45 days prior to the most
recent ESRD episode (item 26). If a dialysis
facility is unable to obtain the laboratory values
from the appropriate care setting within 30 days,
the dialysis facility may use admission laboratory
values drawn prior to initiating the first treatment
at the facility LDL and HbA1c should be within 1
year of the most recent ESRD episode (item 35).
These tests may not be required for patients
under 21 years of age (LDL or HbA1c unless the
child is a diabetic).
21.

(a) Serum Albumin value (g/dl) and date test
was taken. This value and date must be within
45 days prior to first dialysis treatment or
kidney transplant. If a dialysis facility is unable
to obtain the laboratory values from the
appropriate care setting within 30 days, the
dialysis facility may use admission laboratory
values drawn prior to initiating the first
treatment at the facility.
(b) Enter the lower limit of the normal range
for serum albumin from the laboratory which
performed the serum albumin test entered in
Serum Albumin.
(c) Enter the serum albumin lab method
used (BCG or BCP).
(d) Enter the serum creatinine value (mg/dl) and
date test was taken. THIS FIELD MUST BE
COMPLETED. Value must be within 45 days
prior to first dialysis treatment or kidney transplant.
If a dialysis facility is unable to obtain the
laboratory values from the appropriate care
setting within 30 days, the dialysis facility may
use admission laboratory values drawn prior to
initiating the first treatment at the facility.
(e) Enter the hemoglobin value (g/dl) and date
test was taken. This value and date must be
within 45 days prior to the first dialysis treatment
or kidney transplant. If a dialysis facility is
unable to obtain the laboratory values from the
appropriate care setting within 30 days, the
dialysis facility may use admission laboratory
values drawn prior to initiating the first
treatment at the facility.
(f) Enter the HbA1c value and the date the test
was taken. The date must be within 1 year prior
to the first dialysis treatment or kidney
transplant.
(g) Enter the LDL value with date test was
taken. The date must be within 1 year prior to
the first dialysis treatment or kidney transplant.
(h) Cystatin C value (mg/l) and date test was
taken. This value and date must be within 45
days prior to first dialysis treatment or kidney
transplant.

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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
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22.

Ask the patient and document if they have
executed a living will or a Medical/Physician
order for life sustaining treatment.

23.

Ask the patient if they have concerns about
where they will live over the next 90 days.

24.

Ask the patient if they have caregiver support
to assist with daily care. Daily care means
actives of daily living, bathing, dressing, etc.
Ask the patient if they have a caregiver to
assist with home dialysis or a kidney transplant.
Ask the patient if the caregiver lives with them.

25.

Ask the patient if they have access to reliable
transportation. Reliable transportation means
the patient can travel to all dialysis treatments,
medical appointments, grocery store,
pharmacy, etc. without issue.

26.

Ask the patient if they can understand health
literature in English. Ask the patient if they
need a different way other than written
documents to learn about their health. Ask the
patient if they need a translator to understand
health information.

27.

Ask the patient if they find it hard to pay for the
very basics like housing, medical care,
electricity, and heating.

28.

Ask the patient if the food they bought has not
lasted and they didn't have money to get more
in the last 12 months.

29.

Ask the patient if anyone, including family and
friends, has threatened them with harm or
physically hurt you in the last 12 months.

30.

Enter the name of the dialysis facility where this
patient is currently receiving care and who is
completing this form for the patient.

31.

Enter the 6-digit CMS Certification Number
(CCN) of the dialysis facility in item 30.

32.

If the person is receiving a regular course of
dialysis treatment, check the appropriate
anticipated long-term treatment setting at
the time this form is being completed.
SNF/LTC: Check this box only if a patient is
residing in a Medicare certified skilled nursing
facility and/or long-term care facility and
receiving dialysis within the nursing facility.
Dialysis may be performed by patient, family,
nursing facility staff, or home dialysis staff, but
the patient is not transported outside the
facility to receive dialysis.
Note: Transitional Care Unit is not included in
item 32 as it is not anticipated that it will
become the long-term treatment center. It is
included in item 50 because it can be a current
setting when a transplant rejection occurs.

33.

If the patient is, or was, on regular dialysis,
check the anticipated long-term primary type of
dialysis: Hemodialysis, (enter the number of
sessions prescribed per week and the minutes
that were prescribed for each session), CAPD
(Continuous Ambulatory Peritoneal Dialysis)
and CCPD (Continuous Cycling Peritoneal
Dialysis), or Other. Check only one block.
NOTE: Other has been placed on this form to
be used only to report IPD (Intermittent

Peritoneal Dialysis) and any new method of
dialysis that may be developed prior to the
renewal of this form by Office of Management
and Budget.
34.

Enter the date (month, day, year) that a
“regular course of chronic dialysis” began. The
beginning of the course of dialysis is counted
from the beginning of regularly scheduled
dialysis necessary for the treatment of end
stage renal disease (ESRD) regardless of the
dialysis setting. The date of the first dialysis
treatment after the physician has determined
that this patient has ESRD and has written a
prescription for a “regular course of dialysis” is
the “Date Regular Chronic Dialysis Began”
regardless of whether this prescription was
implemented in a hospital/ inpatient,
outpatient, or home setting and regardless
of any acute treatments received prior to
the implementation of the prescription.

NOTE: For these purposes, end stage renal disease
means irreversible damage to a person’s kidneys
so severely affecting his/her/their ability to remove
or adjust blood wastes that in order to maintain life
he/she/they must have either a course of dialysis or
a kidney transplant to maintain life.
If re-entering the Medicare program, enter
beginning date of the current ESRD episode. Note
in Remarks, Item 74, that patient is restarting
dialysis.
35. Enter date patient started chronic dialysis at
current facility of dialysis services. In cases where
patient transferred to current dialysis facility, this
date will be after the date in Item 34
36. Enter whether the patient has been informed of
and understands their options for receiving a
kidney transplant. Dialysis facilities are
required to inform patients of their rights to
transplant and other renal replacement
modality options at 42 CFR § 494.70(a)(7).
To be informed a patient must understand the
material. The patient must be able to repeat:
benefits and risk of transplant as a treatment
option, the referral and evaluation process, and
post-transplant recovery and coordination.
Additionally, the patient should be able to
verbalize why they did not choose transplant as
a treatment option.
37. If the patient has not been informed of their
options or does not understand their
transplant options (answered “no” to Item
36), then enter all reasons why a
transplant was not an option for this patient
at this time. If a patient was overwhelmed
by the information or refused information at
this time, the patient should be
approached again within a six-month
period and the option considered at least
at every care conference. Cognitive
impairment should be checked if the
patient has trouble remembering,
learning new things, concentrating, or
making decisions that affect their
everyday life patients and others should
not be listed as having an absolute
medical contraindication if there is a

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potential for a transplant center to work
with the patient.
38. Enter if the patient was connected to a
transplant center for referral along with the
date. 42 CFR § 494.90 (a)(7)(ii) indicates
the interdisciplinary team must make plans
for pursuing the transplant. The dialysis
facility is responsible for assisting the
patient in coordinating with the transplant
center.
39. Enter whether the patient has been
informed of and understands their options
for receiving dialysis in a home setting.
Dialysis facilities are required to inform
patients of their rights to transplant and
other renal replacement modality
options at 42 CFR § 494.70(a)(7). To be
informed a patient must understand the
material. The patient must be able to
repeat: benefits and risk of home dialysis
as a treatment option. Additionally, the
patient should be able to verbalize why
they did not choose home dialysis as a
treatment option.
40. If the patient has not been informed of their
options or does not understand their home
dialysis options (answered “no” to Item
39), then enter all reasons why home
dialysis was not an option for this patient at
this time. If a patient was overwhelmed by
the information or refused information at
this time, the patient should be
approached again within a six-month
period and the option considered at least
at every care conference. Cognitive
impairment should be checked if the
patient has trouble remembering,
learning new things, concentrating, or
making decisions that affect their
everyday life patients and others should
not be listed as having an absolute
medical contraindication if there is a
potential for a home dialysis provider to
work with the patient.
41. Enter the date(s) of the patient’s kidney
transplant(s). If reentering the Medicare
program, enter current transplant date.
42. Enter the name of the hospital where the patient
received a kidney transplant on the date in Item
41.
43. Enter the 6-digit CMS Certification Number
(CCN) of the hospital in Item 42 where the
patient received a kidney transplant on the date
entered in Item 41.
44. Enter date patient was admitted as an inpatient
to a hospital in preparation for, or anticipation of, a
kidney transplant prior to the date of the actual
transplantation. This includes hospitalization for
transplant workup in order to place the patient
on a transplant waiting list.
45. Enter the name of the hospital where patient
was admitted as an inpatient in preparation for,
or anticipation of, a kidney transplant prior to
the date of the actual transplantation.

46. Enter the 6-digit CMS Certification Number
(CCN) for hospital in Item 45.
47. Check the appropriate functioning or nonfunctioning block.
48. Enter the type of kidney transplant, Deceased
Donor, Living Related, Living Unrelated, Multiorgan, or Paired Exchange that the patient
received.
49. If transplant is nonfunctioning, enter date
patient returned to a regular course of dialysis.
If patient did not stop dialysis post-transplant,
enter transplant date.
50. If applicable, check where patient is receiving
dialysis treatment following transplant rejection.
A nursing home or skilled nursing facility is only
an option if a home modality is being received
within the nursing facility not if a certified incenter dialysis facility operates on the grounds.
Note: Transitional Care Unit is not included in
item 32 as it is not anticipated that it will
become the long-term treatment center. It is
included in item 50 because it can be a current
setting when a transplant rejection occurs.
Self-dialysis Training Patients (Medicare Applicants
Only) Normally, Medicare entitlement begins with the
third month after the month a patient begins a regular
course of dialysis treatment. This 3-month qualifying
period may be waived if a patient begins a self-dialysis
training program in a Medicare approved training
facility and is expected to self-dialyze after the
completion of the training program. Please complete
items 51-58 if the patient has entered into a self-dialysis
training program. Items 51-58 must be completed if the
patient is applying for a Medicare waiver of the 3-month
qualifying period for dialysis benefits based on
participation in a self-care dialysis training program.
51. Enter the name of the provider furnishing selfcare dialysis training.
52. Enter the 6-digit CMS Certification Number
(CCN) for the training provider in Item 51.
53. Enter the date self-dialysis training began.
54. Check the appropriate block which describes
the type of self- care dialysis training the patient
began. If the patient trained for hemodialysis,
enter whether the training was to perform
dialysis in the home setting or in the facility (in
center). If the patient trained for IPD
(Intermittent Peritoneal Dialysis), report as
Other.
55. Check the appropriate block as to whether or
not the physician certifies that the patient is
expected to complete the training successfully
and self-dialyze on a regular basis.
56. Enter date patient completed or is expected to
complete self- dialysis training.
57. Enter printed name and signature of the
attending physician or the physician familiar
with the patient’s self-care dialysis training.
58. Enter the National Provider Identifier (NPI) of

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physician in Item 57. (See Item 61 for
explanation of NPI.)
59. Enter the name of the physician who is
supervising the patient’s renal treatment at the
time this form is completed.
60. Enter the area code and telephone number of
the physician who is supervising the patient’s
renal treatment at the time this form is
completed.
61. Enter the National Provider Identifier (NPI) of
physician in Item 59. The Administrative
Simplification provisions of the Health
Insurance Portability and Accountability Act of
1996 (HIPAA) mandate the adoption of a
standard unique health identifier for each health
care provider. The National Provider Identifier
(NPI) final rule, published on January 23, 2004,
establishes the NPI as this standard. All health
care providers and entities covered under
HIPAA must comply with the requirements of
the NPI final rule (45 CFR Part 162, CMS0045-F). Effective May 23, 2008, the NPI
replaced the UPIN as a unique identifier. This
change request updates chapter 14, of
Pub.100-08, Medicare Program Integrity
Manual, by removing information related to the
issuance and maintenance of UPIN and
replacing this information with information
about obtaining NPI and UPIN data. The NPI
registry allows users to perform simple queries
to retrieve read-only information from NPPES.
For example, users may search by the NPI or
legal business name to locate the NPPES
records and search for an individuals or
organizations. The NPI Registry will return the
results of the query to the user, and the user
will click on the record(s) he/she wants to view.
https://npiregistry.cms.hhs.gov/
62. To be signed by the physician supervising the
patient’s kidney treatment. Signature of
physician identified in Item 57. A stamped
signature is unacceptable unless required by a
disability. An electronic signature is
permissible. Providers using electronic systems
need to recognize that there is a potential for
misuse or abuse with alternate signature
methods. For example, providers need a
system and software products that are
protected against modification, etc., and should
apply adequate administrative procedures that
correspond to recognized standards and laws.
The individual whose name is on the alternate
signature method and the provider bear the
responsibility for the authenticity of the
information for which an attestation has been
provided. Physicians are encouraged to check
with their attorneys and malpractice insurers
concerning the use of alternative signature
methods. If the physician chooses to use a wet
signature it should be in ink.

prior to the form being signed, the timeframe
for a signature is extended to 75 days. The
expectation of CMS is that the transferring
facility will make every effort to obtain the
physician signature and will cooperate with the
receiving facility in this effort.
64. If the patient had decided initially not to file
an application for Medicare, the physician
will be re-certifying that the patient is end
stage renal, based on the same medical
evidence, by signing the copy of the CMS-2728
that was originally submitted and returned to
the provider. If you do not have a copy of the
original CMS-2728 on file, complete a new
form. To be signed by the physician who is
currently following the patient.
65. The date physician re-certified and signed the
form.
66. This remarks section may be used for any
necessary comments by either the physician,
patient, ESRD Network or social security field
office. If re-entering the Medicare program it
should be entered here.
67. The patient’s signature authorizing the release
of information to the Department of Health and
Human Services must be secured here. The
signature may be electronic; however, the
dialysis facility bears the burden in
obtaining documentation that the patient
has consented to the use of electronic
signature.
If the patient is unable to sign the form, it
should be signed by a relative, a person
assuming responsibility for the patient or
by a survivor. If a signature cannot be
obtained because the patient is lost to followup, moved outside of the United States or its
territories, or has expired check the correct
box. If the patient has expired provide the date
of death.

63. Enter the date the physician signed this form.
This date should be within the 45 days allowed
to complete the form. If a patient is transferred

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