Applicants to the Texas Kidney Health Care (KHC) Program need documentation of their end-stage renal disease treatment. This physician assessment is used when a signed and dated copy of the applicant's CMS 2728 form is not available. The physician records the type of treatment and key dates, the ICD code and description, and their own details including NPI.
The applicant's treating physician completes the applicant information, medical information and physician information sections and signs the acknowledgment that the facts are true and correct from personal knowledge.
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Kidney Health Care Program Physician Assessment
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When a signed and dated copy of the applicant's CMS 2728 form is not available. The physician completes Form 3057 instead, and the applicant's social worker submits it with the Kidney Health Care Program application.
Whether the applicant receives facility hemodialysis (with start date at the current facility), home hemodialysis or peritoneal dialysis (with training start date and type: CAPD, CCPD or home hemodialysis), or a transplant (with transplant date, preparation date and hospital), plus the ICD code and description.
The physician completes and signs the form and returns it to the applicant's social worker. The social worker submits it to the Texas HHSC Kidney Health Care Program along with the application, Form 3035.