Frequently asked questions (faqs)

A list of common FAQs the Network has received is provided below:

CMS 2728 - Medical Evidence Report Form

If a patient is not applying for Medicare benefits at the time the 2728 is completed do I still send the form to the local Social Security office?
No, however; keep a copy in the patient's file so that when he/she applies you can send that form to the Social Security office.

Can I request a 2728 from the Network for a patient who has transferred into my facility?
The Network no longer processes requests for copies of 2728 forms.  With the June 14, 2012 release of CROWNWeb, facilities have the capability to look up patients and download forms, as needed, through CROWNWeb. For information on how to look up patients or download forms in CROWNWeb, visit   

What do I do if a patient cannot sign the 2728?
A patient signature is required on all 2728 forms.  If the patient is unable to sign, a family member or someone authorized to act on the patient's behalf should be asked to sign.

CMS 2746 - Death Notification Form

If a patient from an outpatient dialysis center is hospitalized or transfers to a "non-ESRD" provider and dies while in the hospital, who is responsible for completing the CMS 2746 form?
It is the facility's responsibility to complete the 2746. However, if the patient has been gone for more than 30 days from a Medicare facility, then dies while under the care of a non-Medicare provider, this event is classified as a CMS death. With CMS death events, the prior Medicare facility is NOT responsible for completion of the 2746 Death Notification.

Missing Forms Report

What needs to be done with this report?
This report lists patients for whom the Network has not received the proper forms. This report is based on the Patient Activity Reports and UNOS reports. This report allows the Network to notify facilities of what specific  information is needed.  Required forms should be entered into CROWNWeb.