Get Form Approved Omb No. 0938-0048 Esrd Death Notification End ...

Filling out the Form Approved OMB No. 0938-0048 ESRD Death Notification is an essential process that ensures accurate documentation regarding the death of patients with end-stage renal disease. This guide provides clear, step-by-step instructions to assist users in completing this form online.

Follow the steps to successfully complete the form online.

1. Click the ‘Get Form’ button to obtain the form and open it in your designated editing application.
2. Begin filling in the patient's last name, first name, and middle initial as they appear on their Medicare card or official SSA documentation.
3. Enter the patient's Medicare claim number as listed on the Medicare card or other official SSA notifications.
4. Indicate the patient's sex by checking the appropriate box — either 'Male' or 'Female.'
5. Fill in the date of birth using the format MM/DD/YYYY, for example, 07/24/2000 for July 24, 2000.
6. Input the patient's Social Security number in the designated field.
7. Enter the two-letter abbreviation for the patient's state of residence (e.g., MD for Maryland).
8. In the 'Place of Death' section, select the location where the patient died by checking the corresponding box.
9. Record the date of death in MM/DD/YYYY format.
10. Select the modality the patient was undergoing at the time of death by checking the appropriate box.
11. Provide the complete name and address of the provider completing the form.
12. Enter the 6-digit Medicare identification code assigned to the provider.
13. In the 'Causes of Death' section, enter the primary cause code from the provided list, and specify any secondary causes if applicable.
14. Indicate whether renal replacement therapy was discontinued prior to death by checking 'Yes' or 'No.' If applicable, check one of the reasons for discontinuation.
15. If the deceased had received a transplant, complete the relevant sections regarding the transplant details.
16. Check whether the patient was receiving hospice care prior to death.
17. Enter the name of the physician who is providing the information for this form.
18. Sign this form and include the date. Ensure to review all entries for accuracy before submission.
19. Once completed, review the form for accuracy, save the changes, and choose whether to download, print, or share the form.

Complete your documents online for a streamlined process.