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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 09380046 09380046 OMB No. XXXXXXXX END STAGE RENAL DISEASE MEDICAL EVIDENCE REPORT MEDICARE ENTITLEMENT

How to fill out form cms-2728-u3 0714

How to fill out form cms-2728-u3 0714?

1. Start by obtaining the form cms-2728-u3 0714. This form is used for end-stage renal disease (ESRD) medical evidence. It is necessary to accurately provide the required information for proper assessment and evaluation.
2. Begin by filling out the personal information section. This includes your name, address, social security number, date of birth, and contact information. Ensure that all the details are accurate and up-to-date.
3. Move on to the section labeled "Patient Identification." Here, you will need to provide specific details regarding your ESRD status. This includes the date of first treatment, date of entitlement, and the ESRD Network name and phone number.
4. The subsequent section pertains to the ESRD facility information. You will need to provide the name, address, and contact details of the facility where you receive your treatment. Additionally, include the contact person's name and phone number.
5. Proceed to the "Treatment History" section. In this section, you should provide a comprehensive account of your treatment history. Include the dates of dialysis, transplant, or other relevant treatments you have received. Include any related hospitalizations or surgeries as well.
6. Complete the "Physician Information" section. Here, provide the name, address, and contact details of your primary care physician as well as any other specialists involved in your ESRD treatment. Include their telephone numbers and the dates of their most recent visits, if applicable.
7. Next, you will find a section related to "Patient's ESRD Treatment Goals." In this part, you can discuss your objectives and plans for managing your ESRD condition. Talk about the treatments you are undergoing, any dietary considerations, and other factors that impact your health.
8. Lastly, carefully review the completed form for accuracy and completeness. Make any necessary corrections or additions before signing the document. Ensure that all the entered information is true and correct to the best of your knowledge.

Who needs form cms-2728-u3 0714?

1. End-stage renal disease (ESRD) patients who require medical evidence should use form cms-2728-u3 0714. This form is specifically designed to gather essential information related to ESRD treatment and history.
2. Healthcare professionals, including physicians and specialists, may also require this form for accurate assessment and evaluation of a patient's ESRD condition. It enables them to understand the treatment history and current status of the patient's renal disease, allowing them to provide appropriate medical care.
3. Additionally, healthcare facilities and ESRD networks utilize this form for record-keeping and statistical analysis purposes. It helps in monitoring the prevalence and management of ESRD within a particular region or facility.

Overall, the form cms-2728-u3 0714 is crucial for ESRD patients, healthcare providers, and facilities involved in the management and treatment of end-stage renal disease.

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