Data Collection

Dialysis Facilities & Transplant Centers

ESRD Medical Evidence Report forms (CMS-2728) completed at treatment initiation or re-entitlement

ESRD Death Notification forms (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.

Important Tips

  • The ESRD facility last responsible for the patient's ongoing care is responsible for completing and submitting the CMS-2746 form if:

    • a patient discontinues treatment or transfers to a "non-ESRD" provider and dies within 30 days,

    • a patient dies within 30 days after being admitted to hospice, a hospital, long term care facility, nursing home or rehab

    • a patient dies while dialyzing as a transient.

  • Facilities using EQRS: The data from the form is entered into EQRS, and no paper should be submitted to the Network office.

  • Facilities not using EQRS (Veterans Administration, Military, and Transplant units):  A copy of the form should be submitted to the Network via fax (610.783.0374).

Annual Facility Survey (CMS-2744)

The ESRD Annual Facility Survey (CMS-2744) is an annual report that dialysis facilities must turn in to their Network. The survey is designed to capture only a limited amount of information concerning each federally-approved renal facility’s operation. It is not intended to yield information on the full range of ancillary services or activities, e.g., referrals, graft outcome, etc.

Every facility/center approved by Medicare to provide services to ESRD patients must furnish the information requested in the ESRD Facility Survey (42 U.S.C. 426; 20 CFR 405, Section 2133). It is also the facility’s/center’s responsibility to provide patient and treatment counts to their local ESRD Network upon termination of operations. Facilities certified as only providing inpatient services are not requested to complete a survey.

The CMS-2744 lists:

  • Patients receiving care at the beginning of the reporting period

  • Patients added to the facility during the reporting period

  • Patient losses at the facility during the reporting period

  • Number of patients present at the facility at the end of the reporting period

  • Patients Medicare enrollment status

  • Hemodialysis patients dialyzing more than four times per week

  • Vocational rehabilitation status of patients

  • Number of Hemodialysis and Other treatments in center

  • Staffing

You cannot delete the CMS-2744 form once you create it. Once submitted, the ESRD Network will review the CMS-2744 and accept it or reject it. 

Forms and Instructions 

Updating Information in EQRS

It is very important that all facilities maintain current facility information in EQRS. The Network uses this information to mail, fax, and e-mail you about various things, such as missing data, educational opportunities, breaking news, emergency events, etc. You should review you facility’s information regularly and check it for accuracy.

  • Changes in address, phone, and fax numbers should be made immediately in EQRS, so that the information always remains up-to-date and we can always reach you.  

  • Hours of operation and shift times should also be updated regularly, so that information is reflected properly on the Dialysis Facility Compare website and Networks can more easily coordinate emergency efforts with your facility staff.

All facility changes can be made in EQRS under the Facility Module:

  • after logging in, simply choose Facilities from the main EQRS page,

  • do a search for your facility by CCN

  • choose your facility from the results by clicking on it, and then,

  • choose Edit Facility from the available options at the top of the page.

Most fields can be edited and you can save your changes by clicking the Submit button at the bottom of the page. If you have any questions you can always contact the Network, or view the training materials at the mycrownweb.org website.