Form Cms-2744b - End Stage Renal Disease Medical Information System Esrd Facility Survey (Transplant Centers Only)

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Form Approved
DEPARTMENT OF HEALTH AND HUMAN SERVICES
OMB No. 0938-0447
CENTERS FOR MEDICARE & MEDICAID SERVICES
FOR THE PERIOD
END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM
ESRD FACILITY SURVEY (TRANSPLANT CENTERS ONLY)
KIDNEY TRANSPLANTS PERFORMED
PATIENTS TRANSPLANTED
TO BE COMPLETED BY
AND DONOR TYPE
KIDNEY TRANSPLANT CENTERS ONLY
Eligibility Status of Patients
Patients
Transplanted at this Facility
who
During the Survey Period
received
Currently
Medicare
Non-Medicare
transplant
enrolled
applica-
at this
U.S. Res.
in
tion
Other
facility
Medicare
pending
42
43
44
45
46
Transplant Procedures Performed
Patients Awaiting
Transplant
at This Facility
Living
Living
Total
Related
Unrelated
Deceased
Fields 47
Dialysis
Nondialysis
Donor
Donor
Donor
thru 49
47
48
49
50
51
52
REMARKS/COMMENTS
COMPLETED BY (Name)
DATE
TITLE
TELEPHONE NO.
This report is required by law (42 USC 426; 42 CFR 405.2133). Individually identifiable patient information will not be disclosed except as provided for in the Privacy Act of 1974
(5 USC 5520; 45 CFR, Part 5a).
Form CMS-2744B (02/04)

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