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2746 Form

IMPORTANT NOTICE: In September 2004, CMS released new Death Notification (CMS-2746) forms. This form was last updated in 1996. A supply of new forms was mailed to all ESRD facilities in September 2004. A copy of the new form is also available for download from the CMS Web site. Please destroy your supply of all old 2746 forms (dated 1996).

2746 Form Frequently Asked Questions (23 KB PDF file opens in new browser)

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Questions

  1. We suspect a patient has passed away, but have no further information. What can we do?
  2. If a patient withdraws from dialysis, is our unit required to complete a 2746?
  3. When a patient transfers to a nursing home, or rehabilitation center, etc, who is responsible for reporting the patient death?
  4. How do we report a patient who has been involuntarily dismissed from our unit?
  5. Which pages of the 2746 should be sent to the Network?
  6. I'm at a dialysis facility, do I need to complete question 15 (transplant information)?
  7. Do I need to write a "0" before 2 digit codes in section 12?
  8. If a patient has not discontinued renal replacement therapy (i.e. answer to 13 is "No"), do I have to complete 13f?

Answers

  1. We suspect a patient has passed away, but have no further information. What can we do?
    Answer: If you suspect that a patient has passed away but do not know the exact date, you can contact the state Vital Records Department to request a copy of the death certificate. See the last page for the address and phone number of your state's department. Top
  2. If a patient withdraws from dialysis, is our unit required to complete a 2746?
    Answer: Facilities are expected to follow a patient for 30 days after a discontinue event, and must submit the CMS-2746 form for patient if death occurs within 30 days.** Top
  3. When a patient transfers to a nursing home, or rehabilitation center, etc, who is responsible for reporting the patient death?
    Answer: CMS requires that data reporting responsibilities for your unit continue for up to 30 days from the date the patient leaves your facility.** Top
  4. How do we report a patient who has been involuntarily dismissed from our unit?
    Answer: While you may report patients as dismissed involuntarily (by selecting loss event option 6C on the PAR), according to CMS policy, dismissed patients remain your responsibility for data reporting up to 30 days from the date of dismissal.** Please note: this does not imply any obligation beyond data reporting. This includes informing Network 11 of any changes in the patient status that you become aware of and filling out the Death Notification form (2746) in the event of death within 30 days of dismissal. Top
  5. Which pages of the 2746 should be sent to the Network?
    Answer: Only the green copy of the 1st page needs to be received in the Network office. It is not necessary to send the instruction page, or the yellow copy. Top
  6. I'm at a dialysis facility, do I need to complete question 15 (transplant information)?
    Answer: If you have information regarding a transplant, it is helpful for you to complete section 15, however it is not necessary. Top
  7. Do I need to write a "0" before 2 digit codes in section 12?
    Answer: It is not necessary to include a zero with 2 digit cause codes. Top
  8. If a patient has not discontinued renal replacement therapy (i.e. answer to 13 is "No"), do I have to complete 13f?
    Answer: No, the date of last dialysis treatment is only required when a patient discontinues dialysis prior to death. Note: if 13 is "Yes" you MUST complete 13f in addition to checking one of the reasons 13a13e. Top

** We understand that it is inconvenient to have patients continue to appear on your PAR (Patient Activity Report) after they have transferred to non-Medicare facilities, discontinued/withdrawn, or were involuntarily dismissed. CMS has established that facilities are responsible for reporting data on such patients for 30 days. Thank you for cooperation.**

Contact Information

If you have questions, call (651) 644-2911 or Email your Network 11 Data Contact:

Facilities in MN, ND, and SD
Sandy Schmidt
Email: sschmidt@nw11.esrd.net

Facilities in WI
Katie Klinsing
Email: kklinsing@nw11.esrd.net

Facilities in Detroit, MI area
Bob Schlichenmaier
Email: bschlichenmaier@nw11.esrd.net

Facilities in Greater MI
Cheryl Dickhausen
Email: cdickhausen@nw11.esrd.net

Click below to download a printable PDF version of these frequently asked questions.