End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration (CMS-2728)
No material or nonsubstantive change to a currently approved collection
No
Regular
05/27/2025
Requested
Previously Approved
11/30/2026
11/30/2026
138,000
138,000
172,500
172,500
0
0
The primary purpose of the END STAGE RENAL DISEASE MEDICAL EVIDENCE REPORT MEDICARE ENTITLEMENT AND/OR PATIENT REGISTRATION is to determine if an individual is entitled to Medicare under the End Stage Renal Disease provisions of the law. This form SHOULD NOT be completed for those patients who are in acute renal failure. Completion of the form is voluntary, but failure to do so may result in denial of Medicare benefits.
US Code:
42 USC 289c
Name of Law: Research on public health emergencies
US Code:
42 USC 426-1
Name of Law: SPECIAL PROVISIONS RELATING TO COVERAGE UNDER MEDICARE PROGRAM FOR END STAGE RENAL DISEASE
US Code:
42 USC 241a
Name of Law: Research and investigations generally
There is a change in total estimated burden hours of 69,000 (172,500 estimated hours- 103,500 previously estimated hours) due to an increase in the time to complete the CMS-2728 forms by 30 minutes and a decrease in submission of CMS-2728 forms by 5,929 submissions (138,000 previously estimated submissions-132,071 submissions).
$1,725,000
No
No
No
No
No
No
No
Denise King 410 786-1013 Denise.King@cms.hhs.gov
No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Form CMS-2728 End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration and Supporting Regulations in 42 CFR, 405.2133; PL 95-292; CFR Parts....
CMS-2728 Non Substantive Change Memo EO14168 and EO14151 clean.docx
End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration and Supporting Regulations in 42 CFR, 405.2133; PL 95-292; CFR Parts....