CMS Form 2728 – Entitlement Form
Background: This form is not just to get Medicare benefits for the patient. It has a dual use for listing the patient in the ESRD Patient Registry (via CROWNWeb) even if they are private pay and specifically not signing up for Medicare ESRD benefits at this time.
2728 DUE DATE – must be submitted within 45 days of admission
The form has been started in CROWNWeb but not completed for one or more of the following reasons:
If for some reason it is physically impossible to create the form such as an undocumented patient returning to his/her home country, or the patient has gone missing for an extended period of time, then please note that on the spreadsheet report that came with the Missing Forms email and send it back to the Network so that we can suppress it from future reports. Otherwise you will keep getting the patient emailed to you each month.
CMS Form 2746 – Death Notification
The 2746 is fairly straightforward. Enter the cause of death. If you do not know the cause of death, enter code 99 in box 12a. For questions 14-16 if you do not know, then answer “Unknown” or “Not Applicable”.
If the patient died within 30 days of discharge, your unit is responsible to complete the 2746.
2746 DUE DATE – must be submitted within 14 days of date of death. If the patient died greater than 30 days after the discharge date in CROWNWeb, then you do NOT need to complete a 2746 form.