CMS-2728 and 2746 Form Archival Requirements

CMS recently provided policy guidance on the printing and archiving of completed CMS-2728 ESRD Medical Evidence and CMS-2746 Death Notification forms.

Per CMS, although CROWNWeb provides a way to electronically submit data directly to CMS, CMS also requires dialysis facilities to retain a print copy of the signed and dated CMS-2728 and CMS-2746 forms at the facility level to assist with data validation efforts. Dialysis facilities should adhere to the following guidelines when completing CMS-2728 and CMS-2746 forms in CROWNWeb:

  • Submit the electronic version of the form to CMS using CROWNWeb.
  • Send the original, signed hardcopy of the form to the Social Security office servicing the claim (CMS-2728 forms only).
  •  Store a copy of the completed, signed form in the patient’s medical records file in accordance with the medical record archival rules in effect in your state.

Find instructions for printing forms at  If you have questions, please call the Network.

Safety & Quality Conference Online June 11

Modern Healthcare will present an online conference on Patient Safety & Quality on June 11, 2013, including sessions on process improvement strategies, data-driven QI, C. difficile, patient-centered leadership, patient involvement in QI, and creating cultures of continuous improvement, quality and safety.  Keynote speakers include Dr. Richard Gilfillan, Director of the CMS Center for Innovation, and Dr. Christine Cassel, President of the National Quality Forum.  For details and registration see .

Patient Poster on Microbes

Northwest Renal Network’s monthly patient flyer is now posted on our website at  The featured topic for May is the normal germs that live on your skin and their care.  These flyers are designed for posting in the facility waiting area, and for distribution to patients and family members.  Contact our Patient Services Director, Lisa Hall ( if you have questions or ideas for future monthly topics.