Get 2728 Form 2020-2025

The 2728 Form is essential for people seeking Medicare entitlement related to end stage renal disease. This guide provides a comprehensive, step-by-step approach to filling out the form online, ensuring you can navigate the process with confidence.

Follow the steps to successfully complete the 2728 Form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient's legal name exactly as it appears on their social security or Medicare card in the designated field.
3. Input the Medicare claim number associated with the patient, ensuring it matches the number on the Medicare card.
4. Provide the patient's social security number as shown on their social security card.
5. Fill in the date of birth using the format MM/DD/YYYY.
6. Enter the patient's mailing address, including street number, city, state, and ZIP code.
7. Include the patient's phone number, ensuring the area code is correct.
8. Indicate the patient's gender by checking the appropriate box.
9. Specify the patient's ethnicity by selecting the correct option and providing country or area of origin if applicable.
10. Check all applicable boxes to indicate the patient's race.
11. Confirm if the patient is applying for ESRD Medicare coverage by selecting 'Yes' or 'No.'
12. List the patient's current medical coverage by checking all relevant options.
13. Measure and enter the patient's height in inches or centimeters.
14. Record the patient's dry weight in pounds or kilograms.
15. Select the primary cause of renal failure from the available options, referencing the appropriate codes.
16. Indicate the patient's employment status, both prior and current.
17. Document co-morbid conditions that apply to the patient by checking all relevant boxes.
18. Provide details regarding prior therapy before ESRD, including information on nephrologists and dietitians if applicable.
19. Enter laboratory values from tests taken within the specified timeframe prior to ESRD episodes.
20. List the name of the dialysis facility providing care.
21. Input the Medicare provider number for the dialysis facility.
22. Select the primary dialysis setting in which the patient is receiving treatment.
23. Note the primary type of dialysis being administered.
24. Record the date that regular chronic dialysis began.
25. Confirm whether the patient has been informed about kidney transplant options.
26. Complete relevant sections for kidney transplant patients if applicable, including dates and hospital details.
27. If applicable, document details about self-dialysis training, including the name of the training provider and dates.
28. Have the attending physician sign and date the form to validate the information.
29. Ensure the patient's signature is secured where indicated.
30. Save your changes, and then download, print, or share the form as needed.

Complete the 2728 Form online to ensure timely processing of your Medicare entitlement.