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.
If a patient discontinues treatment or transfers to a "non-ESRD" provider and dies within 30 days, your facility is responsible for completing and submitting the CMS-2746 form.
If a patient dies while dialyzing as a transient, the patient's home base dialysis center is responsible for completing and submitting the CMS-2746 form.
For those facilities who use CROWNWeb, the data from the form is entered into the CROWNWeb system, and no paper should be submitted to the Network office. For those facilities (Veterans Administration and Transplant units) who do not use CROWNWeb, the green copy is submitted to the Network office and the white copy is retained by the facility for the patient's record.
Page last updated: 9/9/2014