A user requires facility editor rights in CROWNWeb to submit the CMS-2728 End Stage Renal Disease Medical Evidence Report. All users may view or print the form. There are three types of CMS-2728 forms:

  • Initial: Completed for all new patients who initially receive a kidney transplant instead of a regular course of dialysis and for patients for whom a physician prescribed a regular course of dialysis because the patient reached a stage of renal impairment that a kidney transplant or regular course of dialysis is necessary to maintain life.
  • Re-entitlement: Completed for patients already entitled to ESRD Medicare benefits and benefits terminated because coverage stopped three years post-transplant or dialysis stopped for more than twelve months.
  • Supplemental: Completed for patients that receive a transplant or trained for self-care dialysis within the first three months of the first date of dialysis on the initial form.

 CMS-2728 resources are: