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  • 2728 Form 2020

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A re-entitlement 2728 form is required when an initial 2728 form has been previously submitted and the patient's Medicare ESRD benefits have been terminated because: The patient recovered function or discontinued dialysis and it has been 1 year are more since the patient received dialysis.

The Form CMS-2728-U3 (End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration) is the primary documentation that a claimant has ESRD. It also provides statistical data for use in monitoring the ESRD program.

The CMS 2728 must be signed by the treating physician (MD or DO) who is knowledgeable of his/her kidney failure. An APRN or PA cannot sign this form in lieu of a physician based on Social Security's definition of "physician." The instructions for the CMS 2728 do not allow the use of signature stamps.

A Supplemental CMS-2728 Form is required when a patient has received a transplant or trained for self-care dialysis within the first three months of the first date of dialysis and the initial 2728 form was submitted.

2728 Forms are to be submitted in EQRS: https://eqrs.cms.gov/. Due within 45 days of the Admit Date (Field 24). Due for all ESRD patients (not AKI patients). A Supplemental/Re-Entitlement is not required if the patient already has Medicare coverage due to age (>65) or due to another medical condition.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232