The CMS-2728 Form is required by CMS for patient entitlement to Medicare benefits based on End Stage Renal Disease (ESRD).


There are three type of scenarios when a 2728 Form is required to be completed.  Forms should be submitted within 10 days from patient’s first dialysis date; but can be submitted up to 45 days after the date of first dialysis. 

  • Initial: Required for all new ESRD patients.  
  • Supplemental: Required when an Initial 2728 has been previously submitted and: A patient transitions to self-care dialysis within the first 3 months of initial dialysis; – or – A patient has a transplant within the first 3 months of initial dialysis. 
  • Re-entitlement: Required when a patient resumes treatment after Medicare benefits have terminated due to: Patient restarting dialysis after one year or more of having recovered function or discontinued dialysis; – or – Patient restarting dialysis after 3 years or more following a transplant; -or – Patient has another transplant, 3 years or more following a transplant, with no dialysis in between