Medical Evidence Reporting Form (CMS-2728)

A Medical Evidence Reporting Form (CMS-2728) should be completed for all patients undergoing regular dialysis after receiving a diagnosis of ESRD and a prescription has been written for a regular course of dialysis treatment. 

• Facilities have 45-days from the date a patient started at current facility to submit a completed 2728. 
• A 2728 is required even if the patient chooses not to apply for or will not qualify for Medicare. 
• The 2728 should be signed in BLUE ink by both the physician and the patient.
  • If the patient is applying for ESRD Medicare Coverage this BLUE-ink signed copy should be sent to the local Social Security Office.
  • Otherwise the BLUE-ink signed copy should be kept in the patient’s file in the event they apply later.
• Facilities using EQRS:  Data from the form is entered into the EQRS system, and no paper should be submitted to the Network office.
• Facilities not using EQRS (i.e. Veterans Administration, Military, and Transplant units): A copy of the signed form should be submitted to the Network via fax (609.490.0835).​

Important Notice Regarding Collection of Race on the CMS-2728

The following instructions regarding the collection of patient race on the CMS-2728 form were recently provided by CMS in CROWN Memo 10-0508-GN:

Ethnicity and race shall be “self-reported” by the patient to be in conformance with current OMB standards. “Self-reported” is defined as the patient’s verbal or written confirmation of ethnicity and race. It is important to note that the current instructions on CMS Form 2728 do not specify that the information on ethnicity and race must be self-reported, and therefore it is likely that in some cases the information is actually “provider-reported.”

CMS instructs the ESRD Networks to educate the ESRD Medicare Provider community on how to correctly document patient ethnicity and race. Whenever possible, providers must document the patient’s self-reported ethnicity (field 8) and race (field 10) on the OMB 2728 Form. In the event that a patient or patient’s family member is unable to self-report their ethnicity and/or race, instruct providers to record this information on behalf of the patient, and acknowledge the absence of the patient’s self-reported ethnicity and race in the remarks area (field 53) by noting that “fields 8-10” were reported by _________.

With the roll-out of the EQRS national release, the ESRD provider community will be required to document whether ethnicity and/or race was self-reported by the patient or by a patient’s family member and if the patient chose not to report their ethnicity and/or race.