Get Death Notification Form

The death notification form is an essential document for reporting the death of a patient with end-stage renal disease. Completing this form online can streamline the process and ensure that accurate information is submitted efficiently.

Follow the steps to complete the death notification form online.

1. Press the ‘Get Form’ button to access the death notification form and open it in your preferred editor.
2. Begin by providing the patient's last name, first name, and Medicare claim number in the designated fields. This information is crucial as it identifies the patient within the medical system.
3. Next, indicate the patient's sex and enter their date of birth. This section is important for establishing the patient's identity.
4. Input the patient's Social Security number to help validate their identity. Also, state their state of residence for further identification.
5. Select the place of death from the available options: hospital, dialysis unit, home, nursing home, or other. Accurate reporting is necessary for record keeping.
6. Enter the date of death in the provided format, ensuring correctness, as this information is vital for reporting.
7. Indicate the modality at the time of death, selecting from options such as in-center hemodialysis, home hemodialysis, CAPD, CCPD, transplant, or other.
8. Fill in the provider's name, address, and provider number to ensure proper documentation and communication within the healthcare system.
9. Specify the causes of death by entering the appropriate codes from the list provided in the form. If there are secondary causes, indicate those as well.
10. Indicate if renal replacement therapy was discontinued prior to death and specify the reason. This information assists in understanding the patient's treatment journey.
11. Answer whether the discontinuation was after a request from the patient or family and provide dates regarding any transplants and statuses relevant to the patient’s treatment.
12. Provide the name and signature of the person completing the form along with the date. This step formalizes the submission.
13. Once all sections are filled, review the information for accuracy, then save changes, download the form, print a copy, or share it as required.

Complete your documents online to ensure timely and accurate submissions.