esrd death notification form (cms-2746)

 

The ESRD Death Notification Form (CMS-2746) is a one-time form completed upon the death of a dialy)sis patient. The purpose of the form is to notify Medicare of the cause and date of a patient's death.  The CMS-2746 form should be completed by the transplant or dialysis center that was last responsible for the ongoing care of the patient, regardless of the place of death.


Important Tips

  • The ESRD facility last responsible for the patient's ongoing care is responsible for completing and submitting the CMS-2746 form if:
    • a patient discontinues treatment or transfers to a "non-ESRD" provider and dies within 30 days,
    • a patient dies within 30 days after being admitted to hospice, a hospital, long term care facility, nursing home or rehab
    • a patient dies while dialyzing as a transient.
  • Facilities using EQRS: The data from the form is entered into EQRS, and no paper should be submitted to the Network office.
  • Facilities not using EQRS (Veterans Administation, Military, and Transplant units):  A copy of the form should be submitted to the Network via fax (804.320.5918) or United States Postal Service (USPS).