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Form 2728-2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the patient's legal name in the designated fields, ensuring it matches their Social Security or Medicare card.
- Input the Health Insurance Claim Number as it appears on the Medicare card for verification.
- Fill in the patient's Social Security number and mailing address, including city, state, and ZIP code.
- Provide the patient's phone number and date of birth using the specified format (MM/DD/YYYY).
- Select the appropriate options for sex, ethnicity, and race from the provided checkboxes.
- Indicate all applicable medical coverage options by checking each relevant box.
- Complete sections regarding employment status and co-morbid conditions by checking all that apply.
- Ensure to fill out laboratory values and dates prior to dialysis treatment or transplant as required.
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