Form Cms-2728-U3 - Esrd Medical Evidence Report Medicare Entitlement And/or Patient Registration Page 2

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C. COMPLETE FOR ALL kIDNEY TRANSPLANT PATIENTS

28. Date of Transplant (mm/dd/yyyy)

29. Name of Transplant Hospital

30. Medicare Provider Number for Item 29

Date patient was admitted as an inpatient to a hospital in preparation for, or anticipation of, a kidney transplant prior to the

date of actual transplantation.

31. Enter Date (mm/dd/yyyy)

32. Name of Preparation Hospital

33. Medicare Provider number for Item 32

34. Current Status of Transplant (if functioning, skip items 36 and 37)

35. Type of Donor:

Functioning

Non-Functioning

Deceased

Living Related

Living Unrelated

36. If Non-Functioning, Date of Return to Regular Dialysis (mm/dd/yyyy) 37. Current Dialysis Treatment Site

Home

Dialysis Facility/Center

SNF/Long Term Care Facility

D. COMPLETE FOR ALL ESRD SELF-DIALYSIS TRAINING PATIENTS (MEDICARE APPLICANTS ONLY)

38. Name of Training Provider

39. Medicare Provider Number of Training Provider (for Item 38)

40. Date Training Began (mm/dd/yyyy)

41. Type of Training

Hemodialysis

Home

In Center

CAPD

CCPD

Other

42. This Patient is Expected to Complete (or has completed) Training

43. Date When Patient Completed, or is Expected to Complete, Training

and will Self-dialyze on a Regular Basis.

(mm/dd/yyyy)

Yes

I certify that the above self-dialysis training information is correct and is based on consideration of all pertinent medical, psychological, and

sociological factors as reflected in records kept by this training facility.

45. UPIN of Physician in Item 44

44. Printed Name and Signature of Physician personally familiar with the patient’s training

a.) Printed Name

b.) Signature

c.) Date (mm/dd/yyyy)

E. PHYSICIAN IDENTIFICATION

46. Attending Physician (Print)

47. Physician’s Phone No. (include Area Code)

48. UPIN of Physician in Item 46

PHYSICIAN ATTESTATION

I certify, under penalty of perjury, that the information on this form is correct to the best of my knowledge and belief. Based on diagnostic

tests and laboratory findings, I further certify that this patient has reached the stage of renal impairment that appears irreversible and

permanent and requires a regular course of dialysis or kidney transplant to maintain life. I understand that this information is intended for

use in establishing the patient’s entitlement to Medicare benefits and that any falsification, misrepresentation, or concealment of essential

information may subject me to fine, imprisonment, civil penalty, or other civil sanctions under applicable Federal laws.

50. Date (mm/dd/yyyy)

49. Attending Physician’s Signature of Attestation (Same as Item 46)

52. Date (mm/dd/yyyy)

51. Physician Recertification Signature

53. Remarks

F. OBTAIN SIGNATURE FROM PATIENT

I hereby authorize any physician, hospital, agency, or other organization to disclose any medical records or other information about my

medical condition to the Department of Health and Human Services for purposes of reviewing my application for Medicare entitlement

under the Social Security Act and/or for scientific research.

54. Signature of Patient (Signature by mark must be witnessed.)

55. Date (mm/dd/yyyy)

G. PRIVACY STATEMENT

The collection of this information is authorized by Section 226A of the Social Security Act. The information provided will be used to determine if an

individual is entitled to Medicare under the End Stage Renal Disease provisions of the law. The information will be maintained in system No. 09-70

0520, “End Stage Renal Disease Program Management and Medical Information System (ESRD PMMIS)”, published in the Federal Register, Vol. 67, No.

116, June 17, 2002, pages 41244-41250 or as updated and republished. Collection of your Social Security number is authorized by Executive Order 9397.

Furnishing the information on this form is voluntary, but failure to do so may result in denial of Medicare benefits. Information from the ESRD PMMIS

may be given to a congressional office in response to an inquiry from the congressional office made at the request of the individual; an individual or

organization for research, demonstration, evaluation, or epidemiologic project related to the prevention of disease or disability, or the restoration

or maintenance of health. Additional disclosures may be found in the Federal Register notice cited above. You should be aware that P.L.100-503, the

Computer Matching and Privacy Protection Act of 1988, permits the government to verify information by way of computer matches.

FORM CMS-2728-U3 (03/06)