Data Forms

Patient Activity Report and Forms Download

Networks collect and verify patient event data using a form entitled the Patient Activity Report. CMS has revised the Patient Activity Report and the Medicare Entitlement And/Or Patient Registration (CMS-2728) form. Dialysis and transplant facilities must use the revised forms effective June 1, 2005. Download the final version of the 2728, Network Patient Activity Report, Network Patient Activity Report Instructions and Event Business Rules and Definitions.

We recommend that you save the enclosed Excel files as your template. Create a new file each month using the template and the Save As option under file to create a new spreadsheet for each month. Data can be entered directly onto the spreadsheet – saving time and minimizing transfer errors.

Click on the links below to download forms:

The Renal Network, Inc.
911 E. 86th Street, Suite 202
Indianapolis, IN 46240
Phone: (317) 257-8265
Fax: (317) 257-8291
Patient Line:
1 (800) 456-6919
Email: [email protected]