Form (2728, 2746) Modification Process Update

To maintain the CMS 2728 and 2746 Forms as documents that are created for a point in time, CMS will be implementing a new standard for the modifying and updating Forms, effective 03/22/2021.

To assist with managing modifications please follow the instructions below.

Requests to modify a 2728 or 2746 Form will only be processed if the Form meets one of the following criteria:

  1. The modification request is made within 5 business days of submitting the Form in EQRS.
  2. If the request is made after 5 business days of submitting the Form in EQRS, the only field that can be modified is field # 23 (Date Regular Chronic Dialysis Began) because it impacts patient coverage.

NOTE: If the modification does not meet the criteria above, then your request will be denied.

You will receive a notification from the Service Center that your request has been either:

  1. Denied
  2. Escalated to the ESRD Network for review

NOTE: Additional documentation may be required before the change is approved.


If a beneficiary has changed their initial decision to apply for Medicare (field 10), the Form should be printed and signed by the physician (see 2728 Form instructions for field 50, 51, and 52). These changes do not require that the Form be adjusted in EQRS. The printed Form with the appropriate comments and signature should be forwarded to the local SSA office for their review.

Thank you in advance for your cooperation.