Forms
CMS-2728 Form
ESRD MEDICAL EVIDENCE REPORT MEDICARE ENTITLEMENT AND/OR PATIENT REGISTRATION
Medical Release Request Form for 2728
CMS-2746 Form
ESRD DEATH NOTIFICATION
NPAR Forms & Instructions:
Network Patient Activity Report (NPAR)
Each dialysis provider is required to submit a monthly Network Patient Activity Report (NPAR). This data collection tool is used to provide current patient status and location. A CMS-designed report, the NPAR is used to track patient activity at the unit. Catagories of additions and losses provide ongoing documentation of patient census and modalities. The NPAR forms are due in the Network office no later than the 10th of every month and must be completed regardless of the patient activity at the unit.
Patient Event Definitions and Business Rules
Network Patient Activity Report (Excel)
Network Patient Activity Report Instructions
Transplant Activity Report (TAR)
The Transplant Activity Report (TAR) form is the Network's monthly tracking form for all transplant activity. Instructions for this form are located on the bottom of the template. The TAR is also designed to capture information for your annual CMS Facility Survey (CMS 2744). All TAR forms are due in the office before the 10th day of every month. These forms are required even if there is not any activity for the month. Please contact the Network if you are experiencing problems completing or understanding these forms:
Transplant Activity Report (Word)
Transplant Activity Report (PDF)
Questions about forms?
Cindy Smith, Data Manager
405.948.2240
csmith@nw13.esrd.net