OMB control number
End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration (CMS-2728)
OMB 0938-0046 · HHS/CMS.
OMB 0938-0046
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.
The latest form for End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration (CMS-2728) expires 2026-11-30 and is listed under ICR 202505-0938-008.
Form CMS-2728 ESRD Medical Evidence Report
CMS-2728 Non Substantive Change Memo EO14168 and EO14151 clean.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....