Form CMS-2746 ESRD Death Notification Form

Form Approved
OMB No. 0938-0048
Expires: 03/31/2027

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

ESRD DEATH NOTIFICATION

End Stage Renal Disease Medical Information System
Complete this ESRD Death Notification form within 2 weeks of the date of death.
• If the patient was a dialysis patient, the dialysis facility last responsible for the patient’s maintenance dialysis (or home
dialysis) must complete this form.
• If the patient was a transplant patient, the transplant center is responsible for completing this form.
If you can’t complete this form in the CMS electronic system, forward a hard copy to the ESRD Network in your region.
1. Last name

First name

2. Medicare Number (if available)
5. Sex of patient
Male 
Female

Middle initial

3. Social Security Number (SSN)

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

6. Patient’s State of residence (2-letter abbreviation)

8. Place of death (select one)
Hospital 
Home
Other 

Dialysis unit 

9. Modality at time of death (select one)
Incenter hemodialysis 
Home hemodialysis 

Nursing home 
CAPD 

10. Name of dialysis facility/transplant center

7. Date of death (mm/dd/yyyy)

Unknown

CCPD 

Transplant 

Other

11. CMS Certification Number (CCN) for item 11 (6 digits)

12. Address of dialysis facility/transplant center (street address, city, state, ZIP code)
13. Causes of death (enter codes from list on form)
Primary cause of death:
Secondary causes of death (list up to 4):

No secondary

If cause of death is other (98) specify here:
14. Renal replacement therapy discontinued prior to death...................................................................................................
If yes, select one of the following:
Following HD and/or PD access failure
Following acute medical complication

Following transplant failure 
Other

Yes

No

Following chronic failure to thrive

Date of last dialysis treatment:
15. Was discontinuation of renal replacement therapy after patient/family
request to stop dialysis?.....................................................................................................

Yes

No 

Unknown 

Not applicable

If yes, check here if related to hospice care.
Yes

No 

Unknown 

Was transplant graft functioning (patient not on dialysis) at time of death?........................................
Did transplant patient resume chronic maintenance dialysis prior to death?.........................................
Did the transplant patient experience a short-term course (acute) of dialysis prior to death?..........

Yes 
Yes 
Yes 

No 
No 
No 

Unknown
Unknown
Unknown

17. Was patient receiving palliative care/hospice care?.................................................................................

Yes 

No 

Unknown

16. Did the patient ever receive a transplant prior to death?.....................................................................
If yes, date of most recent transplant (mm/dd/yyyy):
Type of transplant received (select one):
Deceased donor 
Living related 

Living unrelated 

Multi-organ 

Paired exchange

18. Name of attending physician (print complete name)
19. Name of person submitting the form

Form CMS-2746-U2 (05/2024)

20. Date (mm/dd/yyyy)

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ESRD DEATH NOTIFICATION FORM LIST OF CAUSES
Cardiac
23 Myocardial infarction, acute
25 Pericarditis, incl. cardiac tamponade
26 Atherosclerotic heart disease
27 Cardiomyopathy
28 Cardiac arrhythmia
29 Cardiac arrest, cause unknown
30 Valvular heart disease
31 Pulmonary edema due to exogenous fluid
32 Congestive Heart Failure

Vascular
35 Pulmonary embolus
36 Cerebrovascular accident including intracranial
hemorrhage
37 Ischemic brain damage/anoxic encephalopathy
38 Hemorrhage from transplant site
39 Hemorrhage from vascular access
40 Hemorrhage from dialysis circuit
41 Hemorrhage from ruptured vascular aneurysm
42 Hemorrhage from surgery (not 38, 39, or 41)
43 Other hemorrhage (not 38-42, 72)
44 Mesenteric infarction/ischemic bowel

Infection
33
34
45
46
47
48
51
52
61
62
63
70

Septicemia due to internal vascular access
Septicemia due to vascular access catheter
Peritoneal access infectious complication, bacterial
Peritoneal access infectious complication, fungal
Peritonitis (complication of peritoneal dialysis)
Central nervous system infection (brain abscess,
meningitis, encephalitis, etc.)
Septicemia due to peripheral vascular disease, gangrene
Septicemia, other
Cardiac infection (endocarditis)
Pulmonary infection (pneumonia, influenza)
Abdominal infection (peritonitis (not comp of PD),
perforated bowel, diverticular disease, gallbladder)
Genito-urinary infection (urinary tract infection,
pyelonephritis, renal abscess)

Liver Disease
64
71
65
66

Hepatitis B
Hepatitis C
Other viral hepatitis
Liver-drug toxicity

67 Cirrhosis
68 Polycystic liver disease
69 Liver failure, cause unknown or other

Gastro-Intestinal
72 Gastro-intestinal hemorrhage
73 Pancreatitis
75 Perforation of peptic ulcer
76 Perforation of bowel (not 75)

Metabolic
24 Hyperkalemia
77 Hypokalemia
78 Hypernatremia
79 Hyponatremia
100 Hypoglycemia
101 Hyperglycemia
102 Diabetic coma
95 Acidosis

Endocrine
96 Adrenal insufficiency
97 Hypothyroidism
103 Hyperthyroidism

Other
80 Bone marrow depression
81 Cachexia/failure to thrive
82 Malignant disease, patient ever on immunosuppressive
therapy
83 Malignant disease (not 82)
84 Dementia, incl. dialysis dementia, Alzheimer’s
85 Seizures
87 Chronic obstructive lung disease (COPD)
88 Complications of surgery
89 Air embolism
90 Accident related to treatment
91 Accident unrelated to treatment
92 Suicide
93 Drug overdose (street drugs)
94 Drug overdose (not 92 or 93)
98 Other cause of death
99 Unknown
104 Withdrawal from dialysis/uremia
105 COVID-19
106 Severe adverse medication reaction

This report is required by law (42, U.S.C. 426; 20 CFR 405, Section 2133). Collection of your Social Security number is authorized by Executive
Order 9397. Individually identifiable patient information will not be disclosed except as provided for in the Privacy Act of 1974 (5 U.S.C. 5520;
45 CFR Part 5a). 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.
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.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-0048 (Expires: 03/31/2027). The time required to
complete this information collection is estimated to average 45 minutes per response, including the time to review instructions, search existing
data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,
Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments, medical
records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not
pertaining to the information collection burden approved under the associated OMB control 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 your ESRD Network.
Form CMS-2746-U2 (05/2024) 2

INSTRUCTIONS FOR COMPLETING OF ESRD DEATH NOTIFICATION: CMS-2746-U2
1. 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.
2. If the patient is covered by Medicare, enter his/her/their
Medicare Number as it appears on his/her/their Medicare
card.

14. Select yes or no to indicate whether or not the patient
voluntarily discontinued renal replacement therapy prior
to death.

4. Enter patient’s date of birth (2-digit month, day, and
4-digit year). Example 07/25/1950.

If yes, select the option that best describes the condition
under which the patient discontinued renal replacement
therapy:
• Following HD and/or PD access failure
• Following transplant failure
• Following chronic failure to thrive
• Following acute medical complication
• Other (select if it was a condition of hospice)

5. Fill in the appropriate circle to identify the patient’s sex.

Enter date of last dialysis treatment.

3. Enter the Social Security Number as it appears on his/her/
their Social Security card.

6. Enter the two-letter United States Postal Service
abbreviation for state in the space provided for the
patient’s state of residence; e.g., MD for Maryland, NY
for New York.
7. Enter patient’s date of death (2-digit month, day, and
4-digit year). Example 07/25/1950.
8. Fill in one circle to indicate the location of the patient at
time of death. In-transit deaths or dead on arrival (DOA)
cases are to be identified by selecting “Other.”
9. Fill in one circle to indicate the patient’s modality at
time of death. “Other” has been placed on the 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 the Office
of Management and Budget.
10. Enter the name of the dialysis facility or transplant
center where this patient last received care and who is
completing this form.
11. Enter the 6-digit CMS Certification Number (CCN) of the
dialysis facility in item 11.
12. Enter the street address of the provider submitting
the form with the city, state and ZIP code in which the
provider is located.
13. Primary cause: Enter the numeric code from the list on
the form, which represents the patient’s primary cause
of death. Do not report the same cause of death for
primary and secondary causes.

15. Select the choice that best applies. Go to item 18 for
definition of hospice.
16. Select yes if the patient ever received a kidney transplant
and complete the remaining question. If the answer is no
continue to question 18.
Enter the date of the most recent transplant in
month, day, and year order using an 8-digit number. If
unknown, check box for unknown.
Select the type of transplant received.
Indicate if the transplant graft was functioning at time
of the patient’s death.
Indicate if the kidney transplant failed and the
transplant patient resume chronic maintenance dialysis
prior to death.
Indicate if the patient had a short-term course of dialysis
to support the kidney transplant prior to death.
17. Hospice is a program of care and support for people who
are terminally ill (with a life expectancy of 6 months or
less, if the illness. Palliative care relieves suffering for
patients with a chronic illness. Patients may receive one
or the other, both, or neither.
18. Print the name of the attending physician.
19. Name of person submitting the form.
20. Date the form was signed.

Identify up to four secondary causes, if available. Enter
the code from the list on the form, which represents the
secondary cause(s) of death. If there was not secondary
cause(s) of death select no secondary.
If cause of death is “Other” (98) please specify the cause.
Notes:
• Code 82: “Malignant disease, patient ever on
immunosuppressive therapy” is for use when the
diagnosis of malignant disease occurred after the
start of immunosuppressive therapy
• Code 104: “Withdrew from dialysis” may not be
reported as a primary cause of death. A primary cause
of death must be selected from the list on the form
which would include “Other (98)” with additional
information entered.

Form CMS-2746-U2 (05/2024)

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