FORM CMS-2728-U3 (06/04)
11. Check the appropriate yes or no block to indicate if patient is
applying for ESRD Medicare. Note: Even though a person may
already be entitled to general Medicare coverage, he/she
should reapply for ESRD Medicare coverage.
12. Check all the blocks that apply to this patient’s current
medical insurance status.
Medicaid—Patient is currently receiving State Medicaid
Medicare—Patient is currently entitled to Federal Medicare
Employer Group Health Insurance—Patient receives medical
benefits through an employee health plan that covers
employees, former employees, or the families of employees or
DVA—Patient is receiving medical care from a Department of
Veterans Affairs facility.
Medicare Advantage—Patient is receiving medical benefits
under a Medicare Advantage organization.
Other Medical Insurance—Patient is receiving medical benefits
under a health insurance plan that is not Medicare, Medicaid,
Department of Veterans Affairs, HMO/M+C organization, nor
an employer group health insurance plan. Examples of other
medical insurance are Railroad Retirement and CHAMPUS
None—Patient has no medical insurance plan.
13. Enter the patient’s most recent recorded height in inches
OR centimeters at time form is being completed. If entering
height in centimeters, round to the nearest centimeter.
Estimate or use last known height for those unable to be
measured. (Example of inches - 62. DO NOT PUT 5’2”) NOTE:
For amputee patients, enter height prior to amputation.
14. Enter the patient’s most recent recorded dry weight in pounds
OR kilograms at time form is being completed. If entering
weight in kilograms, round to the nearest kilogram.
NOTE: For amputee patients, enter actual dry weight.
15. To be completed by the attending physician. Enter the ICD-
9-CM from back of form to indicate the primary cause of end
stage renal disease. These are the only acceptable causes of
end stage renal disease.
16. Check the first box to indicate employment status 6 months
prior to renal failure and the second box to indicate current
employment status. Check only one box for each time period.
If patient is under 6 years of age, leave blank.
17. To be completed by the attending physician. Check all
co-morbid conditions that apply.
*Cerebrovascular Disease includes history of stroke/
cerebrovascular accident (CVA) and transient ischemic attack
*Peripheral Vascular Disease includes absent foot pulses,
prior typical claudication, amputations for vascular disease,
gangrene and aortic aneurysm.
*Drug dependence means dependent on illicit drugs.
18. Prior to ESRD therapy, check the appropriate box to indicate
whether the patient received Exogenous erythropoetin (EPO)
or equivalent, was under the care of a nephrologist and/or was
under the care of a kidney dietitian. Provide vascular access
information as to the type of access used (Arterio-Venous Fistula
(AVF), graft, catheter (including port device) or other type of
access) when the patient first received outpatient dialysis. If an
AVF access was not used, was a maturing AVF or graft present?
NOTE: For those patients re-entering the Medicare program after
benefits were terminated, Items 19a thru 19c should contain initial
laboratory values within 45 days prior to the most recent ESRD
episode. Lipid profiles and HbA1c should be within 1 year of the
most recent ESRD episode. Some tests may not be required for
patients under 21 years of age.
19a1. Enter the serum albumin value (g/dl) and date test was taken.
This value and date must be within 45 days prior to first
dialysis treatment or kidney transplant.
19a2. Enter the lower limit of the normal range for serum albumin
from the laboratory which performed the serum albumin test
entered in 19a1.
19a3. Enter the serum albumin lab method used (BCG or BCP).
19b. Enter the serum creatinine value (mg/dl) and date test was
taken. THIS FIELD MUST BE COMPLETED. Value must be within
45 days prior to first dialysis treatment or kidney transplant.
19c. Enter the hemoglobin value (g/dl) and date test was taken.
This value and date must be within 45 days prior to the first
dialysis treatment or kidney transplant.
19d. Enter the HbA1c value and the date the test was taken. The
date must be within 1 year prior to the first dialysis treatment
or kidney transplant.
19e. Enter the Lipid Profile values and date test was taken. These
values: TC–Total Cholesterol; LDL–LDL Cholesterol; HDL–HDL
Cholesterol; TG–Triglycerides, and date must be within 1 year
prior to the first dialysis treatment or kidney transplant.
20. Enter the name of the dialysis facility where patient is
currently receiving care and who is completing this form for
21. Enter the 6-digit Medicare identification code of the dialysis
facility in item 20.
22. If the person is receiving a regular course of dialysis treatment,
check the appropriate anticipated long-term treatment setting
at the time this form is being completed.
23. If the patient is, or was, on regular dialysis, check the
anticipated long-term primary type of dialysis: Hemodialysis,
(enter the number of sessions prescribed per week and
the hours that were prescribed for each session), CAPD
(Continuous Ambulatory Peritoneal Dialysis) and CCPD
(Continuous Cycling Peritoneal Dialysis), or Other. Check only
one block. NOTE: Other has been placed on this form to be
used only to report IPD (Intermittent Peritoneal Dialysis) and
any new method of dialysis that may be developed prior
to the renewal of this form by Office of Management and
24. Enter the date (month, day, year) that a “regular course of
chronic dialysis” began. The beginning of the course of dialysis
is counted from the beginning of regularly scheduled dialysis
necessary for the treatment of end stage renal disease (ESRD)
regardless of the dialysis setting. The date of the first dialysis
treatment after the physician has determined that this patient
has ESRD and has written a prescription for a “regular course
of dialysis” is the “Date Regular Chronic Dialysis Began”
regardless of whether this prescription was implemented in a
hospital/ inpatient, outpatient, or home setting and regardless
of any acute treatments received prior to the implementation
of the prescription.
NOTE: For these purposes, end stage renal disease means
irreversible damage to a person’s kidneys so severely affecting
his/her ability to remove or adjust blood wastes that in order to
maintain life he or she must have either a course of dialysis or a
kidney transplant to maintain life.
If re-entering the Medicare program, enter beginning date of the
current ESRD episode. Note in Remarks, Item 53, that patient is
25. Enter date patient started chronic dialysis at current facility of
dialysis services. In cases where patient transferred to current
dialysis facility, this date will be after the date in Item 24.
26. Enter whether the patient has been informed of their options
for receiving a kidney transplant.
27. If the patient has not been informed of their options
(answered “no” to Item 26), then enter all reasons why a
kidney transplant was not an option for this patient at