The ESRD Death Notification Form (CMS-2746) is a one-time form completed when a dialysis patient dies. The purpose of the form is to notify Medicare of the date and cause of a patient's death. 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. Important Tips • If a patient discontinues treatment or transfers to a "non-ESRD" provider and dies within 30 days, your facility is responsible for completing and submitting the CMS-2746 form. • If a patient dies within 30 days after being admitted to hospice, a hospital, long term care facility, nursing home or rehab, the patient's dialysis unit is responsible for completing the CMS-2746 form. • If a patient dies while dialyzing as a transient, the patient's home base dialysis center is responsible for completing and submitting the CMS-2746 form. For those facilities that use CROWNWeb, the data from the form is entered into the CROWNWeb system, and no paper should be submitted to the Network office. For those facilities (Veterans Administration and Transplant units) that do not use CROWNWeb, a copy of the form is submitted to the Network via fax or United States Postal Service (USPS).