Data Collection

Dialysis Facilities and Transplant Centers

• ESRD Medical Evidence Report forms (CMS-2728) completed at treatment initiation or re-entitlement
  • ​List of Primary Causes of Renal Failure ICD-10 Codes
• ESRD Death Notification forms (CMS-2746)
• Annual Facility Survey (CMS-2744)
• Facility Staffing Update Form

Dialysis Facility Data Tracking Forms

The form below should be completed monthly as part of your internal process of tracking patient activity throughout the year to properly prepare for the annual CMS 2744.
 

• Monthly Caseload Changes/Census Report