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Data Collection Forms

Below is list of forms maintained by the USRDS Coordinating Center with direct links to the forms themselves. Note that some forms are now available solely in electronic format and so are not reproduced here. Copies of the legacy paper forms are maintained for historical purposes.

 

CMS 2728 Medical Evidence Report

2018 2015 2005 1995 1987

CMS 2746 ESRD Death Notification

2018 2004 1996 1976

CMS 2744 Facility Survey 

Current
Current

 

The United States Renal Data System (USRDS) Standard Analysis Files (SAFs) include Medicare Parts A and B final-action claims and Medicare Part D prescription drug events. These claims are curated and specially formatted for users of USRDS data. Thus, the Researcher’s Guide to the USRDS Database is the primary resource that users should consult.

Nevertheless, many details of the elements in claims data can be best understood from the perspective of claim forms, billing instructions, and Medicare data dictionaries. We offer the following resources for users who focus on claims data.

CMS-1450 (UB04)

This claim form is used by institutional health care providers, including acute care hospitals, skilled nursing facilities, and outpatient dialysis facilities. This form is used to submit claims to Medicare Parts A and B.

Current

CMS-1500 (UB92)

This claim form is used by physicians and suppliers, including durable medical equipment vendors. This form is used to submit claims to Medicare Part B.

Current

Other helpful links:

Centers for Medicare and Medicaid Services End-Stage Renal Disease (ESRD) Center

Chronic Conditions Data Warehouse

Medicare Claims Processing Manual

Research Data Assistance Center (ResDAC)