Form Cms-2728-U3 - Esrd Medical Evidence Report Medicare Entitlement And/or Patient Registration
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6DEPARTMENT OF HEALTH AND HUMAN SERVICES
Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0046
END STAGE RENAL DISEASE MEDICAL EVIDENCE REPORT
MEDICARE ENTITLEMENT AND/OR PATIENT REGISTRATION
A. COMPLETE FOR ALL ESRD PATIENTS
Check one:
Initial
Re-entitlement
Supplemental
1. Name (Last, First, Middle Initial)
2. Medicare Claim Number
3. Social Security Number
4. Date of Birth (mm/dd/yyyy)
5. Patient Mailing Address (Include City, State and Zip)
6. Phone Number (including area code)
7. Sex
8. Ethnicity
9. Country/Area of Origin or Ancestry
Male
Female
Not Hispanic or Latino
Hispanic or Latino (Complete Item 9)
10. Race (Check all that apply)
11. Is patient applying for
ESRD Medicare coverage?
White
Asian
Black or African American
Native Hawaiian or Other Pacific Islander*
Yes
No
American Indian/Alaska Native
*complete Item 9
Print Name of Enrolled/Principal Tribe ______________________________
12. Current Medical Coverage (Check all that apply)
13. Height
14. Dry Weight
15. Primary Cause of Renal
Failure
(Use code from back of form)
Medicaid
Medicare
Employer Group Health Insurance
INCHES ______ OR
POUNDS ______ OR
DVA
Medicare Advantage
Other
None
CENTIMETERS ______
KILOGRAMS ______
17. Co-Morbid Conditions
(Check all that apply currently and/or during last 10 years) *See instructions
16. Employment Status (6 mos prior and
a.
Congestive heart failure
n.
Malignant neoplasm, Cancer
current status)
b.
Atherosclerotic heart disease ASHD
o.
Toxic nephropathy
c.
Other cardiac disease
p.
Alcohol dependence
d.
Cerebrovascular disease, CVA, TIA*
q.
Drug dependence*
Unemployed
e.
Peripheral vascular disease*
r.
Inability to ambulate
Employed Full Time
f.
History of hypertension
s.
Inability to transfer
Employed Part Time
g.
Amputation
t.
Needs assistance with daily activities
Homemaker
h.
Diabetes, currently on insulin
u.
Institutionalized
i.
Diabetes, on oral medications
1. Assisted Living
Retired due to Age/Preference
j.
Diabetes, without medications
2. Nursing Home
Retired (Disability)
k.
Diabetic retinopathy
3. Other Institution
Medical Leave of Absence
l.
Chronic obstructive pulmonary disease
v.
Non-renal congenital abnormality
w
Student
m.
Tobacco use (current smoker)
.
None
18. Prior to ESRD therapy:
a. Did patient receive exogenous erythropoetin or equivalent?
Yes
No
Unknown
If Yes, answer:
6-12 months
>12 months
b. Was patient under care of a nephrologist?
Yes
No
Unknown
If Yes, answer:
6-12 months
>12 months
c. Was patient under care of kidney dietitian?
Yes
No
Unknown
If Yes, answer:
6-12 months
>12 months
d. What access was used on first outpatient dialysis:
AVF
Graft
Catheter
Other
If not AVF, then: Is maturing AVF present?
Yes
No
Is maturing graft present?
Yes
No
19. Laboratory Values Within 45 Days Prior to the Most Recent ESRD Episode. (Lipid Profile within 1 Year of Most Recent ESRD Episode).
LABORATORY TEST
VALUE
DATE
LABORATORY TEST
VALUE
DATE
a.1. Serum Albumin (g/dl)
___ . ___
d. HbA1c
___ ___ . ___%
a.2. Serum Albumin Lower Limit
___ . ___
e. Lipid Profile
TC
___ ___ ___
a.3. Lab Method Used (BCG or BCP)
___ ___ ___
LDL
b.
Serum Creatinine (mg/dl)
___ ___ . ___
___ ___
HDL
c.
Hemoglobin (g/dl)
___ ___ . ___
TG
___ ___ ___ ___
B. COMPLETE FOR ALL ESRD PATIENTS IN DIALYSIS TREATMENT
20. Name of Dialysis Facility
21. Medicare Provider Number (for item 20)
22. Primary Dialysis Setting
23. Primary Type of Dialysis
Home
Dialysis Facility/Center
SNF/Long Term Care Facility
Hemodialysis (Sessions per week____/hours per session____)
CAPD
CCPD
Other
24. Date Regular Chronic Dialysis Began (mm/dd/yyyy)
25. Date Patient Started Chronic Dialysis at Current Facility (mm/dd/yyyy)
26. Has patient been informed
27. If patient NOT informed of transplant options, please check all that apply:
of kidney transplant options?
Medically unfit
Patient declines information
Unsuitable due to age
Yes
No
Patient has not been assessed
Psychologically unfit
Other
FORM CMS-2728-U3 (03/06)
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