Esrd Death Notification Form
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4DEPARTMENT OF HEALTH AND HUMAN SERVICES
Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0048
ESRD DEATH NOTIFICATION
END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM
1. Patient’s Last Name
First
MI
2. Medicare Claim Number
3. Patient’s Sex
4. Date of Birth
5. Social Security Number
___ ___ / ___ ___ / ___ ___ ___ ___
a.
Male
b.
Female
Month
Day
Year
6. Patient’s State of Residence
7. Place of Death
8. Date of Death
a.
Hospital
c.
Home
e.
Other
___ ___ / ___ ___ / ___ ___ ___ ___
b.
Dialysis Unit
d.
Nursing Home
Month
Day
Year
9. Modality at Time of Death
a.
Incenter Hemodialysis
b.
Home Hemodialysis
c.
CAPD
d.
CCPD
e.
Transplant
f.
Other
10. Provider Name and Address (Street)
11. Provider Number
Provider Address (City/State)
12. Causes of Death (enter codes from list on back of form)
a. Primary Cause: ___ ___ ___
b. Were there secondary causes?
No
Yes, specify: ___ ___ ___
___ ___ ___
___ ___ ___
___ ___ ___
c. If cause is other (98) please specify: ___________________________________________________________________________
14. Was discontinuation of renal
13. Renal replacement therapy discontinued prior to death:
Yes
No
replacement therapy after patient/
If yes, check one of the following:
family request to stop dialysis?
a.
Following HD and/or PD access failure
b.
Following transplant failure
Yes
No
c.
Following chronic failure to thrive
d.
Following acute medical complication
Unknown
Not Applicable
e.
Other
f. Date of last dialysis treatment ___ ___ / ___ ___ / ___ ___ ___ ___
Month
Day
Year
15. If deceased ever received a transplant:
16.Was patient receiving Hospice care
prior to death?
___ ___ / ___ ___ / ___ ___ ___ ___
a. Date of most recent transplant
Unknown
Month
Day
Year
Yes
No
b. Type of transplant received
Unknown
Living Related
Living Unrelated
Deceased
Unknown
c. Was graft functioning (patient not on dialysis) at time of death?
Yes
No
Unknown
d. Did transplant patient resume chronic maintenance dialysis prior to death?
Yes
No
Unknown
17. Name of Physician (Please print complete name)
18. Signature of Person Completing this Form
Date
This report is required by law (42, U.S.C. 426; 20 CFR 405, Section 2133). Individually identifiable patient information will not be
disclosed except as provided for in the Privacy Act of 1974 (5 U.S.C. 5520; 45 CFR Part 5a).
Form CMS-2746-U2 (08/06)
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