DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-0447 END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM ESRD FACILITY SURVEY (TRANSPLANT CENTERS ONLY) FOR THE PERIOD KIDNEY TRANSPLANTS PERFORMED PATIENTS TRANSPLANTED AND DONOR TYPE TO BE COMPLETED BY KIDNEY TRANSPLANT CENTERS ONLY Patients who received transplant at this facility Eligibility Status of Patients Transplanted at this Facility During the Survey Period Currently enrolled in Medicare Medicare Non-Medicare applicaU.S. Res. tion Other pending 42 43 44 45 46 Transplant Procedures Performed at This Facility Living Related Donor Living Total Unrelated Deceased Fields 47 Donor Donor thru 49 Patients Awaiting Transplant Dialysis Nondialysis 47 48 49 50 51 52 REMARKS/COMMENTS COMPLETED BY (Name) DATE TITLE TELEPHONE NO. This report is required by law (42 USC 426; 42 CFR 405.2133). Individually identifiable patient information will not be disclosed except as provided for in the Privacy Act of 1974 (5 USC 5520; 45 CFR, Part 5a). Form CMS-2744B (02/04) American LegalNet, Inc. www.USCourtForms.com