Get 2728 Form 2015

Filling out the 2728 Form 2015 online is a straightforward process that ensures proper documentation for Medicare entitlement related to end stage renal disease. This guide will provide comprehensive, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to successfully complete the 2728 Form 2015 online.

1. Click ‘Get Form’ button to obtain the document and open it in your preferred online editor.
2. Begin by entering the patient's legal name (Last, First, Middle Initial) as it appears on their Social Security card.
3. Input the Health Insurance Claim Number found on the patient's Medicare card.
4. Enter the patient’s Social Security Number, verifying it against their Social Security card.
5. Provide the full mailing address of the patient, including street address, city, state, and ZIP code.
6. Enter the patient’s phone number, ensuring to include the area code.
7. Fill in the patient's date of birth using the format MM/DD/YYYY.
8. Choose the appropriate option to indicate the patient's sex.
9. Select the patient's ethnicity from the specified categories.
10. Identify the patient’s race by checking one of the provided boxes.
11. Indicate the patient’s medical coverage by checking all applicable boxes for current insurance status.
12. Specify if the patient is applying for ESRD Medicare coverage by selecting 'Yes' or 'No' and provide the address of the Social Security office if yes.
13. Complete the primary cause of renal failure using the corresponding code from the back of the form.
14. Record the patient's height in inches or centimeters.
15. Input the patient’s dry weight in pounds or kilograms.
16. Select the employment status of the patient for the past six months and their current status from the options provided.
17. Check all co-morbid conditions that apply to the patient based on their medical history.
18. Indicate if EPO was administered prior to the dialysis treatment or transplant.
19. Fill out laboratory values prior to the first dialysis treatment or transplant as required.
20. Provide the name and Medicare provider number of the current dialysis provider.
21. Select the primary dialysis setting from the available options.
22. Choose the primary type of dialysis being utilized.
23. Enter the date regular dialysis began, in MM/DD/YYYY format.
24. If applicable, enter the date dialysis stopped.
25. If the patient has deceased, input the date of death.
26. Review all completed fields for accuracy.
27. Save changes, then download, print, or share the completed form as needed.

Take the next step in managing your health by completing the 2728 Form 2015 online today.