Form 2746

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).

Information regarding changes to 2746 form
This message is being provided on behalf of the Centers for Medicare & Medicaid Services (CMS) and the Division of Kidney Health (DKH). The purpose of...
Thu, Sep 10, 2020 at 10:54 AM
New 2728 / 2746 Forms (Effective in EQRS)
2728 Form (dated 10/2018) 2746 Form (Dated 10/2018)
Thu, Sep 10, 2020 at 10:55 AM
2746 per Discontinued Patients
If a patient chooses to discontinue dialysis and passes away within 30 days of date of discontinuation, the dialysis facility is responsible for completi...
Thu, Nov 30, 2017 at 2:11 PM
Form CMS 2746 – Codes added for COVID-19 Deaths
Please be advised that CMS has added death codes to the CMS 2746 form in CROWNWeb specifically to capture deaths related to COVID-19. The new codes are F...
Mon, May 4, 2020 at 8:56 AM