Form CMS-2728-U3 (06/2024)
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25. Ask the patient if they have access to reliable transportation. Reliable transportation means the patient can travel to all
dialysis treatments, medical appointments, grocery store, pharmacy, etc. without issue.
26. Ask the patient if they can understand health literature in English. Ask the patient if they need a different way other than
written documents to learn about their health. Ask the patient if they need a translator to understand health information.
27. Ask the patient if they find it hard to pay for the very basics like housing, medical care, electricity, and heating.
28. Ask the patient if the food they bought has not lasted and they didn’t have money to get more in the last 12 months.
29. Ask the patient if anyone, including family and friends, has threatened them with harm or physically hurt you in the last
12 months.
30. Enter the name of the dialysis facility where this patient is currently receiving care and who is completing this form for the
patient.
31. Enter the 6-digit CMS Certification Number (CCN) of the dialysis facility in item 30.
32. 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.
• SNF/LTC: Check this box only if a patient is residing in a Medicare certified skilled nursing facility and/or long-term care
facility and receiving dialysis within the nursing facility. Dialysis may be performed by patient, family, nursing facility
staff, or home dialysis staff, but the patient is not transported outside the facility to receive dialysis.
Note: Transitional care unit is not included in item 32 as it is not anticipated that it will become the long-term
treatment center. It is included in item 50 because it can be a current setting when a transplant rejection occurs.
33. 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 minutes that were prescribed for each session), CAPD (Continuous
Ambulatory Peritoneal Dialysis) and CCPD (Continuous Cycling Peritoneal Dialysis), or Other. Select only one option.
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 Budget.
34. 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/their ability to remove or adjust blood wastes that in order to maintain life he/she/they 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 74, that
patient is restarting dialysis.
35. 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 34
36. Enter whether the patient has been informed of and understands their options for receiving a kidney transplant. Dialysis
facilities are required to inform patients of their rights to transplant and other renal replacement modality options
at 42 CFR § 494.70(a)(7). To be informed a patient must understand the material. The patient must be able to repeat:
benefits and risk of transplant as a treatment option, the referral and evaluation process, and post-transplant recovery
and coordination. Additionally, the patient should be able to verbalize why they did not choose transplant as a treatment
option.
37. If the patient has not been informed of their options or does not understand their transplant options (answered “no”
to item 36), then enter all reasons why a transplant was not an option for this patient at this time. If a patient was
overwhelmed by the information or refused information at this time, the patient should be approached again within a
six-month period and the option considered at least at every care conference. Cognitive impairment should be checked if
the patient has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday
life patients and others should not be listed as having an absolute medical contraindication if there is a potential for a
transplant center to work with the patient.
38. Enter if the patient was connected to a transplant center for referral along with the date. 42 CFR § 494.90 (a)(7)(ii)
indicates the interdisciplinary team must make plans for pursuing the transplant. The dialysis facility is responsible for
assisting the patient in coordinating with the transplant center.
39. Enter whether the patient has been informed of and understands their options for receiving dialysis in a home setting.
Dialysis facilities are required to inform patients of their rights to transplant and other renal replacement modality
options at 42 CFR § 494.70(a)(7). To be informed a patient must understand the material. The patient must be able to
repeat: benefits and risk of home dialysis as a treatment option. Additionally, the patient should be able to verbalize why
they did not choose home dialysis as a treatment option.