ESRD Death Notification Form (CMS-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

• The ESRD facility last responsible for the patient's ongoing care is responsible for completing and submitting the CMS-2746 form if:
  • a patient discontinues treatment or transfers to a "non-ESRD" provider and dies within 30 days,
  • a patient dies within 30 days after being admitted to hospice, a hospital, long term care facility, nursing home or rehab
  • a patient dies while dialyzing as a transient.
• Facilities using EQRS: The data from the form is entered into EQRS, and no paper should be submitted to the Network office.
• Facilities not using EQRS (Veterans Administation, Military, and Transplant units):  A copy of the form should be submitted to the Network via fax (609.490.0835).