The CMS-2746 Form is a one-time form required by CMS when a dialysis patient dies.  The purpose of the form is to notify Medicare of the date and cause of a patient's death.  for patient entitlement to Medicare benefits based on End Stage Renal Disease (ESRD).  

The 2746 form is to be completed by the transplant or dialysis center that was last responsible for the care of the patient on an ongoing basis, regardless of the place of death including these scenarios: 


  • a patient discontinues treatment or transfers to a "non-ESRD" provider and dies within 30 days,
  • a patient dies within 30 days after being admitted to hospice, a hospital, long term care facility, nursing home or rehab
  • a patient dies while dialyzing as a transient