DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-0448 ESRD DEATH NOTIFICATION END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM 1. Patient's Last Name First MI 2. Medicare Claim Number 3. Patient's Sex a. s Male b. s Female 4. Date of Birth 5. Social Security Number Year c. d. _ ss _ _ / _Day / _ _ _ _ Month Year Month Day 6. Patient's State of Residence 7. Place of Death a. b. 8. Date of Death s Hospital s Dialysis Unit s Home e. s Other s Nursing Home c. s CAPD d. s CCPD __/__/____ Month Day Year 9. Modality at Time of Death a. s Incenter Hemodialysis b. s Home Hemodialysis e. s Transplant f. s Other 10. Provider Name and Address (Street) 11. Provider Number Provider Address (City/State) 12. Causes of Death (enter codes from list on back of form) a. Primary Cause ___ b. Were there secondary causes? s s No Yes, specify: ___ ___ ___ ___ C. If cause is other (98) please specify:___________________________________________________________________ ss s sss sss sss 13. Renal replacement therapy discontinued prior to death: If yes, check one of the following: a. b. c. d. e. f. s Following HD and/or PD access failure s Following transplant failure s Following chronic failure to thrive s Following acute medical complication s Other Date of last dialysis treatment s Yes s No 14. Was discontinuation of renal replacement therapy after patient/family request to stop dialysis? s Yes s Unknown Day Year s No s Not Applicable _ _ / _ _ / _ _ _ _ ss ss ssss Month 15. If deceased ever received a transplant: a. Date of most recent transplant _ _ Month /__/____ Day Year s Unknown 16. Was patient receiving Hospice care prior to death? b. Type of transplant received s Living Related s Living Unrelated s Deceased s Unknown s Yes s No c. Was graft functioning (patient not on dialysis) at time of death? s Yes s No s Unknown d. Did transplant patient resume chronic maintenance dialysis prior to death? s Yes s No s Unknown 17. Name of Physician (Please print complete name) s Unknown 18. Signature of Person Completing This Form Date This report is required by law (42, U.S.C. 426; 20 CFR 405, Section 2133). 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). Form CMS-2746-U2 (08/06) EF 08/2006 American LegalNet, Inc. www.FormsWorkflow.com 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 Septicemia due to internal vascular access 34 Septicemia due to vascular access catheter 45 Peritoneal access infectious complication, bacterial 46 Peritoneal access infectious complication, fungal 47 Peritonitis (complication of peritoneal dialysis) 48 Central nervous system infection (brain abscess, meningitis, encephalitis, etc.) 51 Septicemia due to peripheral vascular disease, gangrene 52 Septicemia, other 61 Cardiac infection (endocarditis) 62 Pulmonary infection (pneumonia, influenza) 63 Abdominal infection (peritonitis (not comp of PD), perforated bowel, diverticular disease, gallbladder) 70 Genito-urinary infection (urinary tract infection, pyelonephritis, renal abscess) LIVER DISEASE 64 Hepatitis B 71 Hepatitis C 65 Other viral hepatitis 66 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 104 Withdrawal from dialysis/uremia 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 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 0938-0448. The time required to complete this information collection is estimated to average 30 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 any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. Form CMS-2746-U2 (08/06) EF 08/2006 American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS FOR COMPLETING OF ESRD DEATH NOTIFICATION CMS-2746-U2 (10/04) ITEM 1. PROCEDURES Patient's Last Name, First, and Middle Initial Enter the patient's last name, first name, and middle initial as it appears on the Medicare Card or other official SSA notification. Medicare Claim Number Enter the patient's Medicare number as it appears on the Medicare Card or other official SSA notification. Patient's Sex Check the box that indicates the patient's sex. Date of Birth Enter the date in month, day, and year order, using an 8-digit number; e.g., 07/24/2000 for July 24, 2000. Social Security Number Enter the patient's own social security number. Patient's State of Residence Enter the two-letter United States Postal Service abbreviation for State in the space provided; e.g., MD for Maryland,