Form CMS-382 ESRD Beneficiary Selection

DEPARTMENT OF HEALTH & HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No. 0938-0372

ESRD BENEFICIARY SELECTION (Home Patients Only)
PLEASE READ INSTRUCTIONS ON REVERSE BEFORE COMPLETING THIS FORM
1. NAME (Last, First, Middle Initial)

2. HEALTH INSURANCE CLAIM NUMBER (Medicare Claim Number)

3. DATE OF BIRTH (month/day/year)

4. SEX

o Male
o Female

5. PROVIDER NUMBER OF FACILITY PROVIDING HOME DIALYSIS TRAINING

5A. NAME AND ADDRESS OF FACILITY PROVIDING HOME DIALYSIS TRAINING

6. PROVIDER NUMBER OF FACILITY PROVIDING HOME DIALYSIS SUPPORT SERVICES

6A. NAME AND ADDRESS OF DIALYSIS FACILITY PROVIDING SUPPORT SERVICES

o
o
o
o

7. BENEFICIARY SELECTION, CHANGE OR CANCELLATION

Initial Selection
Cancellation
Routine Method Selection Change

o
o
o

8. TYPE OF DIALYSIS (Check One)
Hemodialysis
CAPD
CCPD

Method Exception (Refer to PRM, Part I-Chap. 27, §2740.2.D.) Intermediary approval required.

Reason for Exception __________________________________________________________________________
____________________________________________________________________________________________
9. DATE HOME DIALYSIS TRAINING IS COMPLETED

o

10. CHECK METHOD I OR II
METHOD I – The ESRD facility indicated in #6 will supply all the equipment, supplies, and support services
necessary for me to dialyze at home.

o

METHOD II – I will deal directly with one supplier for my home dialysis supplies and equipment, and my
support services will be provided by the dialysis facility indicated above.

11. NAME AND ADDRESS OF THE DURABLE MEDICAL EQUIPMENT SUPPLIER THAT WILL PROVIDE THE SUPPLIES
AND EQUIPMENT (Only appropriate if beneficiary chooses Method II)

12. If I have chosen Method II, by signing this form, I certify that I have only one Method II supplier. Further, I understand that if my
supplier does not take assignment, Medicare will not pay anything toward my supplier’s bill.

o Private Residence

o Skilled Nursing Facility

13. CHECK LOCATION WHERE HOME DIALYSIS IS PROVIDED

14. BENEFICIARY SIGNATURE

o Nursing Home
15. DATE BENEFICIARY SIGNS FORM (month/day/year)

16. DATE METHOD EXCEPTION TO BE EFFECTIVE (month/day/year)

(INITIAL SELECTION CHANGES, ROUTINE SELECTION CHANGES, AND CANCELLATIONS BECOME EFFECTIVE ON JANUARY 1 OF THE YEAR FOLLOWING THE YEAR IN WHICH THIS FORM IS SIGNED)

17. The dialysis facility providing the home dialysis training is responsible for supplying this form to Medicare beneficiaries who select home dialysis
and for sending the white copy of the completed form to the local Part A Intermediary (both Method I and Method II selections). Blank forms are
available from the Intermediary. The white copy of this form must be sent to:
THE LOCAL INTERMEDIARY
ATTN: MEDICARE PROGRAM ADMINISTRATOR
A copy of the form must also be sent to the dialysis facility providing support services and to the supplier if the beneficiary chooses Method II.
Form CMS-382 (01/05) EF 02/2005

1

INSTRUCTIONS FOR COMPLETING THE ESRD BENEFICIARY SELECTION FORM
METHOD CHANGES – Once you have made your
initial selection, your reimbursement must be handled
in that manner until December 31 of the year in which
you signed the ESRD Beneficiary Selection form. If
you wish to continue your initial selection beyond
December 31, you do NOT complete another ESRD
Beneficiary Selection form. You will automatically
continue to have your reimbursement handled in the
manner you selected. If you do not wish to continue
with your initial selection beyond December 31, you
MUST complete another ESRD Beneficiary Selection
form. This subsequent form must be signed, dated and
This form is to be filled out only by Medicare
postmarked PRIOR to January 1 of the year you wish
beneficiaries dialyzing at home and not by Medicare your selection change to be effective. This is the only
beneficiaries who are currently dialyzing in a facility. way changes are made, and this is the only reason you
should ever complete more than one ESRD
Your selection of either Method I or Method II in no
Beneficiary Selection form.
way inhibits your return to incenter treatment or selection
for any other treatment options should that be necessary.
PRIVACY ACT STATEMENT
METHOD I – The first method is for your dialysis
As required by 5 U.S.C. 552a (the Privacy Act of
facility to assume the responsibility for your care.
Under this method, the facility is required to provide 1974), you are advised that the Centers for Medicare
& Medicaid Services is authorized to collect the data
to you any and all dialysis equipment, supplies and
on this form by Section 1881(b)(1) of the Social
home support services that you need to dialyze at
home. It also is required to order, store, deliver, and
Security Act and 42 CFR 405.544. The purpose for
pay the manufacturers and suppliers for these items.
collecting this information is stated above. Your
Under this arrangement you are responsible to your
response to the questions on this form is not required
dialysis facility for the Medicare Part B deductible
by law. However, if you do not provide this informaand 20% coinsurance.
tion, requests for end-stage renal dialysis reimbursement may be denied or delayed until it is provided.
METHOD II – While your facility is responsible for You should be aware that the information you provide
assuring that you receive all items and services that
may be verified by a computer match (P.L. 100-503).
you require for home dialysis, the second method
allows you to deal directly with a single supplier for
Individually identifiable patient information will not
securing the necessary dialysis equipment and supplies. be disclosed except as provided for by the Privacy Act.
Then your supplier bills the Medicare program for
payment. Under this arrangement, you are responsible
to the supplier for the Medicare Part B deductible and
20% coinsurance.
Centers for Medicare & Medicaid Services regulations
provide two (2) ways that a Medicare beneficiary
dialyzing at home can choose to have the Medicare
program pay for his/her dialysis care (exclusive of
physician services). The purpose of the Beneficiary
Selection form is for you, the beneficiary, to select the
method that best suits your requirements. It is important
you choose one of these two methods, complete and
sign the form and return it to the dialysis facility that
supervises your care as soon as possible. You must
complete all sections of this form.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0938-0372. The time required to complete this information collection is estimated
to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and
review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form,
please write to CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
Form CMS-382 (01/05) EF 02/2005

2