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Medicare Claim Number 3. Social Security Number 4. Date of Birth MM 5. Patient Mailing Address Include City State and Zip 7. Sex 8. Ethnicity s Male s Female DD YYYY 6. Phone Number 9. Country/Area of Origin or Ancestry s Not Hispanic or Latino 10. Race Check all that apply s White s Black or African American s American Indian/Alaska Native s Hispanic or Latino Complete Item 9 s Asian s Native Hawaiian or Other Pacific Islander 11. Is patient applying for ESRD Medicare coverage s Yes s No compl ...

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What is a 2728 form?

The Form CMS-2728-U3 (End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration) is the primary documentation that a claimant has ESRD. It also provides statistical data for use in monitoring the ESRD program.

How do you get Part A and B with ESRD?

You can sign up for Part A and Part B by contacting your local Social Security office or by calling Social Security at 1-800-772-1213. TTY users can call 1-800-325-0778.

What is a re entitlement 2728?

A re-entitlement 2728 form is required when an initial 2728 form has been previously submitted and the patient's Medicare ESRD benefits have been terminated because: The patient recovered function or discontinued dialysis and it has been 1 year are more since the patient received dialysis.

What is a 2746 form?

The ESRD Death Notification Form (CMS-2746) is a one-time form completed when a dialysis patient dies. The purpose of the form is to notify Medicare of the date and cause of a patient's death.