Loading
Get Cms Cms-2746-u2 2025-2026
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the CMS CMS-2746-U2 online
Filling out the CMS CMS-2746-U2 is essential for reporting the death of a patient with end-stage renal disease. This guide will assist you in completing the form accurately and effectively, ensuring timely submission.
Follow the steps to fill out the CMS CMS-2746-U2 online.
- Click ‘Get Form’ button to obtain the form and open it for editing.
- Enter the patient’s legal name, ensuring it matches exactly with their Social Security or Medicare card.
- If applicable, input the Medicare number as it appears on the patient’s Medicare card.
- Enter the Social Security Number as shown on the patient's Social Security card.
- Provide the patient's date of birth in the format (mm/dd/yyyy). For example, 07/25/1950.
- Choose the appropriate circle for the patient’s sex; options include male and female.
- Input the two-letter abbreviation for the patient's state of residence, e.g., MD for Maryland.
- Enter the date of death using the format (mm/dd/yyyy).
- Select one option to indicate the location of death, such as hospital, home, or other.
- Select the modality at the time of death from the provided options.
- Input the name of the dialysis facility or transplant center responsible for the patient.
- Enter the 6-digit CMS Certification Number (CCN) for the facility.
- Provide the complete address of the dialysis facility or transplant center.
- For causes of death, enter the numeric code for the primary cause from the designated list.
- Indicate whether renal replacement therapy was discontinued prior to death by selecting yes or no.
- If the patient received a transplant, complete the relevant questions regarding transplant status and the dates.
- Print the name of the attending physician in the appropriate field.
- Write the name of the person submitting the form.
- Enter the date when the form is being signed.
- Once all fields are completed, save your changes, and download or print the form as needed.
Complete your CMS CMS-2746-U2 form online now for timely submission.
Related links form
The 2746 form refers specifically to the CMS form 2746, which is vital for collecting information related to dialysis patients. This form facilitates the documentation of patient data and allows healthcare providers to maintain compliance with Medicare reporting requirements. Utilizing the CMS CMS-2746-U2 streamlines the process, ensuring effective communication between providers and the CMS.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.