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Data Manual

If you are currently using CROWNWeb you will not need the information below. CROWNWeb is programmed to not allow invalid 2728 or 2746 forms to be created and submitted. Additionally, CROWNWeb users should not use the PAR (Patient Activity Report). If you are NOT using CROWNWeb, the information below is critical for correct submission of patient information.

Target Audience: Dialysis staff responsible for filling out CMS Eligibility or Death Notices, and monthly PARs (Patient Activity Reports)

These instructions are intended to help you successfully understand the CMS 2728 Eligibility Form, the CMS 2746 Death Form, and the Patient Activity Report.

If the instructions are unclear or omit specific information, please contact Serena Timko at 816-880-1707 for assistance.

Please remember that submitting forms with missing or inaccurate information will count against your facility's Forms Compliance Score that is measured every January and July.

• How forms errors are identified.
• Sample CMS-2728 with lab ranges and recommended uses.
• Blank copy of CMS-2728 for your use.
• Blank copy of CMS-2746
• Forms Manual, also called the "Data Manual". (We recommend that you save this Word document to your local computer for easier navigation with the built in hyperlinked menu. Click on FILE | SAVE AS and save it to a folder on your computer.
• What to do with Acute Patients and Form 2728s

© 2011 End-Stage Renal Disease (ESRD) #12 Network Coordinating Council, Inc. dba Heartland Kidney Network
This resource was (created, developed, compiled, etc.) while under contract with Center for Medicare and Medicaid Services, Baltimore, Maryland. Contract #HHSM-500-2010-NW012C. The contents presented do not necessarily reflect CMS policy.