CMS-2728: who signs the ESRD Medical Evidence Report and where it goes

The signed CMS-2728 goes to the patient's local Social Security office as a hard copy, by fax or by email, with the CMS-43 application. The dialysis facility completes the form in EQRS within 45 days of the start of dialysis or a transplant, and the ESRD Network only answers questions about where to send it.

What is the CMS-2728, and when is it filed?

The CMS-2728, the End Stage Renal Disease Medical Evidence Report, Medicare Entitlement and/or Patient Registration, must be completed within 45 days for every patient beginning a course of dialysis or a transplant, and it should not be completed for a patient in acute renal failure. The title names the form's two jobs, Medicare entitlement and patient registration, and its authority is Section 226A of the Social Security Act.

The current report is Form CMS-2728-U3 (06/2025), OMB 0938-0046, which CMS shows expiring 11/30/2026. A renewed version may replace it after that date, so use the version CMS lists.

The form has three reasons to file. An initial form is the first report for a patient beginning dialysis or a transplant. Re-entitlement is for a beneficiary who stopped dialysis for more than 12 months, had Medicare ESRD benefits terminated and has returned to dialysis or received a kidney transplant. A supplemental form reports a transplant or self-care dialysis training in a patient's first 3 months of dialysis, after the initial form.

The date regular chronic dialysis began is the date of the first dialysis treatment after the physician has determined the patient has ESRD and written a prescription for a regular course of dialysis. The setting does not matter, whether the prescription was implemented in a hospital, an outpatient setting or at home, and acute treatments before the prescription do not change the date.

Who completes and signs the CMS-2728?

The dialysis facility completes the CMS-2728 in the ESRD Quality Reporting System (EQRS) and prints it, the attending physician completes items 13, 15-16, 32-36 and 58-59 and certifies the form under penalty of perjury, and the patient signs the release of information to HHS.

The dialysis facility also provides the applicant with a copy of the form or assists in submitting it to the Social Security office.

The physician certifies, under penalty of perjury, that the information on the form is correct to the best of the physician's knowledge and belief. A stamped physician signature is unacceptable unless a disability requires it, and an electronic signature is permissible. If the patient transfers before the form is signed, the time for a signature extends to 75 days.

The patient's signature authorizes release of information to the Department of Health and Human Services. It may be electronic, but the dialysis facility bears the burden of documenting that the patient consented to an electronic signature.

Where does the signed CMS-2728 go?

The signed CMS-2728 goes to the Social Security office in the applicant's area, as a hard copy, by fax or by email, and the dialysis facility gives the applicant a copy or helps submit it.

The form's instruction to the applicant is to forward a hard, fax or email copy with signatures to the Social Security office in the area. The patient's CMS-43 application for Part A and Part B for people with end-stage renal disease goes to the same office by fax or mail, together with the CMS-2728 from the provider. The regional ESRD Network takes only questions about where to submit documents, the form says, and CMS says 18 Network Organizations operate across the United States and its territories. Confirm the local office's fax number with the office before sending.

The table lists each step, who does it, where it goes and the rule that applies.

When does Medicare start for a dialysis patient?

Medicare coverage for a dialysis patient usually starts on the first day of the fourth month of dialysis treatments, Medicare.gov says, and 42 CFR 406.13 gives the example that if dialysis began in January, entitlement begins April 1.

Entitlement is a separate step from the CMS-2728: the patient files the CMS-43 application, which may be retroactive for up to 12 months. An application is not valid if it is filed earlier than the third month before the month in which the individual meets the conditions of entitlement.

A relative or other person responsible for the patient's affairs may file the application for a patient who cannot because of physical or mental condition, and the hospital or dialysis facility that furnished treatment may file it if no responsible person is available. That rule is about filing the application, and it leaves the physician's items on the CMS-2728 with the attending physician.

What gets a CMS-2728 delayed or rejected?

A CMS-2728 runs into trouble when it breaks one of the form's own instructions: a stamped physician signature, a form completed for acute renal failure, a missed 45-day window, an expired version, or a signed copy sent to an ESRD Network instead of the Social Security office.

• A stamped signature: the form calls it unacceptable unless a disability requires it, while an electronic signature is permissible.
• A form for acute renal failure: the form says it should not be completed for patients in acute renal failure.
• A missed window: the 45 days is the form's own rule for completion, and the 75 days applies only to the physician's signature after the patient transfers before signing.
• A copy sent to the wrong place: the ESRD Network answers questions about where to submit, and the signed copy goes to the Social Security office.
• An expired version: CMS shows Form CMS-2728-U3 expiring 11/30/2026, so use the version CMS lists.

How do transplant centers and home dialysis programs use the same form?

Transplant centers and home dialysis training programs use the CMS-2728 as a supplemental form when a patient receives a transplant or trains for self-care dialysis within the first 3 months of the first date of dialysis, after the initial form was submitted.

The CMS-43 application travels with the CMS-2728 to the same Social Security office.

Other Medicare enrollment paperwork also moves by fax, as in answering a Medicare enrollment development request, and Social Security field offices take other faxed forms, covered in faxing documents to Social Security.

How do you fax the CMS-2728 to Social Security securely?

A dialysis facility assisting the applicant sends the signed CMS-2728 to the local Social Security office through a HIPAA fax service that has signed a BAA with the facility, and uses a number the office can fax back to. Fax Pigeon signs that BAA at signup on every plan, and a paid plan gives the facility its own fax number for the office's reply. Every delivered fax gets delivery proof, and How to tell if a fax went through lists the facts that record should carry. A cover sheet is optional, and the facility's staff can route each reply through a shared inbox with roles and assignment.

* Official sources (CMS, Medicare.gov, the Code of Federal Regulations at govinfo.gov) were read on October 26, 2026. Fax Pigeon prices and plan terms as of October 26, 2026.