DEPARTMENT OF HEALTH AND HUMAN SERVICES Form Approved CENTERS FOR MEDICARE & 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 Claim Number 3. Social Security Number 4. Date of Birth MM DD  YYYY 5. Patient Mailing Address (Include City, State and Zip) 6. Phone Number ( ) 7. Sex 8. Ethnicity 9. Country/Area of Origin or Ancestry
Male
Female
Not Hispanic or Latino
Hispanic or Latino (Complete Item 9) 10. Race (Check all that apply) 11. Is patient applying for ESRD
White
Asian Medicare coverage?
Black or African American
Native Hawaiian or Other Pacific Islander*
Yes
No
American Indian/Alaska Native Print Name of Enrolled/Principal Tribe _________________ *complete Item 9 12. Current Medical Coverage (Check all that apply) 13. Height 14. Dry Weight 15. Primary Cause of Renal
Medicaid
Medicare
Employer Group Health Insurance INCHES _______ OR POUNDS _______ OR Failure (Use code from back of form)
DVA
Medicare Advantage
Other
None CENTIMETERS _______ _ KILOGRAMS _______ 16. Employment Status (6 mos prior and 17. Co-Morbid Conditions (Check all that apply currently and/or during last 10 years)*See instructions current status) a.
Congestive heart failure n.
Malignant neoplasm, Cancer b.
Atherosclerotic heart disease ASHD o.
Toxic nephropathy c.
Other cardiac disease p.
Alcohol dependence PriorCurrent d.
Cerebrovascular disease, CVA, TIA* q.
Drug dependence*

Unemployed e.
Peripheral vascular disease* r.
Inability to ambulate

Employed Full Time f.
History of hypertension s.
Inability to transfer

Employed Part Time g.
Amputation t.
Needs assistance with daily activities

Homemaker h.
Diabetes, currently on insulin u.
Institutionalized i.
Diabetes, on oral medications
1. Assisted Living

Retired due to Age/Preference j.
Diabetes, without medications
2. Nursing Home

Retired (Disability) k.
Diabetic retinopathy
3. Other Institution

Medical Leave of Absence l.
Chronic obstructive pulmonary disease v.
Non-renal congenital abnormality

Student m.
Tobacco use (current smoker) w.
None 18. Prior to ESRD therapy: a. Did patient receive exogenous erythropoetin or equivalent?
Yes
No
Unknown If Yes, answer:
6-12 months
>12 months b. Was patient under care of a nephrologist?
Yes
No
Unknown If Yes, answer:
6-12 months
>12 months c. Was patient under care of kidney dietitian?
Yes
No
Unknown If Yes, answer:
6-12 months
>12 months d. What access was used on first outpatient dialysis:
AVF
Graft
Catheter
Other If not AVF, then: Is maturing AVF present?
Yes
No Is maturing graft present?
Yes
No 19. Laboratory V45 alues Within Days Prior to the Most Recent ESRD Episode. (Lipid Profile within 1 Year of Most Recent ESRD Episode). LABORATORY TEST VALUE DATE LABORATORY TEST VALUE DATE a.1. Serum Albumin (g/dl) d. HbA1c ___ . ___ ___ ___ . ___% a.2. Serum Albumin Lower Limit e. Lipid Profile TC ___ . ___ ___ ___ ___ a.3. Lab Method Used (BCG or BCP) LDL ___ ___ ___ b. Serum Creatinine (mg/dl) HDL ___ ___ . ___ ___ ___ c. Hemoglobin (g/dl) ___ ___ . ___ TG ___ ___ ___ ___ B. COMPLETE FOR ALL ESRD PATIENTS IN DIALYSIS TREATMENT 20. Name of Dialysis Facility 21. Medicare Provider Number (for item 20) 22. Primary Dialysis Setting 23. Primary Type of Dialysis
Home
Dialysis Facility/Center
SNF/Long Term Care Facility
Hemodialysis (Sessions per week____/hours per session____)
CAPD 
CCPD
Other 24. Date Regular Chronic Dialysis Began 25. Date Patient Started Chronic MM DD YYYY Dialysis at Current Facility MM DD YYYY 26. Has patient been informed of kidney transplant options? 27. If patient NOT informed of transplant options, please check all that apply:
Yes
No
Medically unfit
Patient declines information
Unsuitable due to age
Patient has not been assessed
Psychologically unfit
Other FORM CMS-2728-U3 (06/04) EF(03/2005) American LegalNet, Inc. www.USCourtForms.com>>>> 2 C. COMPLETE FOR ALL KIDNEY TRANSPLANT PATIENTS 28. Date of Transplant 29. Name of Transplant Hospital 30. Medicare Provider Number for Item 29 MM DD YYYY Date patient was admitted as an inpatient to a hospital in preparation f or, or anticipation of, a kidney transplant prior to the date of actual transplantation. 31. Enter Date 32. Name of Preparation Hospital 33. Medicare Provider number for Item 32 MM DD YYYY 34. Current Status of Transplant (if functioning, skip items 36 and 37) 35. Type of Donor:
Functioning
Non-Functioning
Deceased
Living Related
Living Unrelated 36. If Non-Functioning, Date of Return to Regular Dialysis 37. Current Dialysis Treatment Site
Home
Dialysis Facility/Center
SNF/Long Term Care Facility MM DD YYYY D. COMPLETE FOR ALL ESRD SELF-DIALYSIS TRAINING PATIENTS (MEDICARE APPLICANTS ONLY) 38. Name of Training Provider 39. Medicare Provider Number of Training Provider (for Item 38) 40. Date Training Began 41. Type of Training
Hemodialysis a.
Home b.
In Center
CAPD
CCPD
Other MM DD YYYY 42. This Patient is Expected to Complete (or has completed)Training 43. Date When Patient Completed, or is Expected to Complete, Training and will Self-dialyze on a Regular Basis.
Yes
No MM DD YYYY I certify that the above self-dialysis training information is correct a nd is based on consideration of all pertinent medical, psychological, and sociological factors as reflected in records kept by this training facility. 44. Printed Name and Signature of Physician personally familiar with the pat ients training 45. UPIN of Physician in Item 44 a.) Printed Name b.) Signature c.) Date MM DD YYYY E. PHYSICIAN IDENTIFICATION 46. Attending Physician (Print) 47. Physicians Phone No. 48. UPINof Physician in Item 46 ( ) PHYSICIAN ATTESTATION I certify, under penalty of perjury, that the information on this form is correct to the best of my knowled ge and belief. Based on diagnostic tests and laboratory findings, I further certify that this patient has r eached 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 patients entitlement to Medicare benefit