PDF
Word
This version of the form is not currently in use and is provided for reference only. Download this version of
Form CMS-2728-U3
for the current year.
Form CMS-2728-U3 End Stage Renal Disease Medical Evidence Report Medicare Entitlement and / or Patient Registration
What Is Form CMS-2728-U3?
This is a legal form that was released by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services on October 1, 2018 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is Form CMS-2728-U3?
A: Form CMS-2728-U3 is the End Stage Renal Disease Medical Evidence Report used for Medicare entitlement and/or patient registration.
Q: Who uses Form CMS-2728-U3?
A: Form CMS-2728-U3 is used by individuals with end-stage renal disease (ESRD) to provide medical evidence for Medicare entitlement and patient registration.
Q: What is the purpose of Form CMS-2728-U3?
A: The purpose of Form CMS-2728-U3 is to gather medical information about a patient's end-stage renal disease in order to determine eligibility for Medicare benefits and to register the patient in Medicare.
Q: What information is required on Form CMS-2728-U3?
A: Form CMS-2728-U3 requires information about the patient's medical history, current dialysis treatments, and other relevant health information.
Form Details:
- Released on October 1, 2018;
- The latest available edition released by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services;
- Easy to use and ready to print;
- Yours to fill out and keep for your records;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a fillable version of Form CMS-2728-U3 by clicking the link below or browse more documents and templates provided by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services.
Download Form CMS-2728-U3 End Stage Renal Disease Medical Evidence Report Medicare Entitlement and / or Patient Registration
1
2
3
4
5
6
7
