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 ESRD Forms

CMS 2728 Medical Evidence Report

2018 (PDF, 195.71 KB)
2015 (PDF, 434.63 KB)
2005 (PDF, 82.6 KB)
1995 (PDF, 313.72 KB)
1987 (PDF, 3.58 MB)

CMS 2746 ESRD Death Notification

2018 (PDF, 81.82 KB)
2004 (PDF, 429.61 KB)
1996 (PDF, 21.75 KB)
1976 (PDF, 507.81 KB)

CMS 2744 Facility Survey

Current CMS 2744 Facility Survey (PDF, 48.5 KB)

USRDS Special Studies Disease Forms

USRDS Case Mix/Adequacy Study, 1992 (PDF, 720.27 KB)
USRDS Retrospective Case Mix Study, 1990 (PDF, 513.1 KB)
USRDS CAPD Peritonitis Study, 1990 (PDF, 370.39 KB)
USRDS Case Mix Severity Study, 1989 (PDF, 932.79 KB)
USRDS Data Validation Study, 1989 (PDF, 684.42 KB)
USRDS EPO & Quality of Life Study (PDF, 1.87 MB)
USRDS Pediatric ESRD Growth & Development Study, 1990 (PDF, 391.18 KB)
USRDS Renal Biopsy Study, 1990 (PDF, 236.71 KB)
Comprehensive Dialysis Study (PDF, 3.61 MB)
Active/Adipose Study (PDF, 3.41 MB)
Dialysis Morbidity and Mortality Special Study (DMMS) Forms, Waves I-IV (PDF, 512.63 KB)

OPTN Data Collection Forms

Transplant Candidate Registration Worksheets (PDF, 2.2 MB)
Transplant Recipient Registration Worksheets (PDF, 4.4 MB)
Transplant Recipient Follow-Up Worksheets (PDF, 5.57 MB)
Historical OPTN Data Collection Forms (PDF, 22.1 MB)

CDC National Surveillance of Dialysis-Associated Disease Forms

Download as PDF (PDF, 2.99 MB)

Other Resources

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-1450 (UB04) (PDF, 536.84 KB)

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 CMS-1500 (UB92) (PDF, 3.67 MB)

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)

Accessibility

If you need assistance with accessibility for the documents on this page, please email usrds@niddk.nih.gov.

Contact USRDS

  Email: usrds@niddk.nih.gov