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 forms below should be completed monthly and faxed to your ESRD Network at (609) 490-0835 by the 10th of each month. For example, January’s reports are due by February 10th.
 

• Monthly Caseload Changes/Census Report