Get When Do You Complete An Esrd Medical Evidence Report Form - Esrdnet17

This guide provides clear instructions for completing the When Do You Complete An Esrd Medical Evidence Report Form - Esrdnet17 online. Designed to support users with varying levels of experience, these instructions will help ensure accurate and complete submissions.

Follow the steps to complete the form accurately and efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Identify the appropriate section for the patient's initial status: Check either 'Initial', 'Re-entitlement', or 'Supplemental' to indicate the reason for submitting the form.
3. Enter the patient's legal name in the designated field (Last, First, Middle Initial) exactly as it appears on official identification documents.
4. Input the patient's Medicare Claim Number if applicable, which is found on the Medicare card.
5. Fill in the patient's Social Security Number, ensuring it is accurate for identification purposes.
6. Enter the Date of Birth using the format mm/dd/yyyy to verify the patient's age and eligibility.
7. Provide the patient's mailing address, including city, state, and zip code for communication needs.
8. Input the patient's phone number including area code to facilitate contact if required.
9. Indicate the patient's sex by checking the appropriate box.
10. Select the patient's ethnicity as required, providing country or area of origin where applicable.
11. Check the appropriate boxes to indicate the patient's race: White, Black or African American, American Indian/Alaska Native, Asian, and Native Hawaiian or Other Pacific Islander, selecting all that apply.
12. Confirm if the patient is applying for ESRD Medicare coverage by checking 'Yes' or 'No'.
13. Categorize the patient's current medical coverage by checking applicable options such as Medicaid, Medicare, and Employer Group Health Insurance, among others.
14. Record the patient's height in inches or centimeters, rounding to the nearest whole number.
15. Provide the patient's dry weight in pounds or kilograms when the form is being filled out.
16. Indicate the primary cause of renal failure by entering the appropriate ICD-9-CM code from the provided list.
17. Select the patient's employment status as of 6 months prior and current to document employment history.
18. Check all applicable co-morbid conditions in the checklist provided.
19. Answer questions on prior treatment, including whether the patient received erythropoietin or was under care by a nephrologist.
20. Complete laboratory values for the patient as required, ensuring dates are within 45 days prior to ESRD episode.
21. For patients currently in dialysis treatment, input the name and Medicare provider number of the dialysis facility.
22. Specify the primary dialysis setting and type used for treatment as required.
23. Document the date when regular chronic dialysis began, formatted as mm/dd/yyyy.
24. Following instruction completion, save the changes, and you can download, print, or share the form as needed.

Complete your forms online today to ensure timely processing of your medical evidence report.