Dialysis facilities and transplant centers complete this report when a patient starts a regular course of dialysis or receives a kidney transplant for end-stage renal disease. It establishes Medicare entitlement under the ESRD provisions and registers the patient in the ESRD program, recording the primary cause of renal failure, comorbidities, pre-ESRD care, lab values and treatment details.
Facility staff such as the head nurse or social worker complete most items. The attending physician completes items 13, 15-16 and 32-36 and signs the attestation in items 58-59; a physician familiar with self-dialysis training signs item 53, and the patient signs items 63-64.
Download the current version from the source each time; forms change without notice.
End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
The attending physician completes items 13 and 15-16 (primary cause of renal failure, comorbid conditions and care before ESRD therapy) and items 32-36 on transplant and home dialysis options, then signs the attestation in items 58-59 certifying that the impairment appears irreversible and requires dialysis or transplant.
It must be completed within 45 days for every patient starting a regular course of dialysis or receiving a first transplant, even if the patient dies within that period. If the patient transfers before the physician signs, the signature window extends to 75 days.
Yes. The instructions permit an electronic physician signature, but a stamped signature is unacceptable unless required by a disability. The patient's signature may also be electronic, though the dialysis facility must document the patient's consent to electronic signature.