2746 Form Frequently Asked Questions

Q: The 2746 form has several copies – what do I send to the Network?

A: Please detach the green copy from the instructions and send to the Network. The yellow copy can be discarded.

Q: When is the 2746 form due to the Network?

A: The 2746 form is due to the Network within 30 days of the patient’s date of death.

Q: I need more 2746 forms. How can I get more?

A: Please contact the Network to request more 2746 forms.

Q: Do we have to submit a 2746 form for a patient who discontinued dialysis?

A: You must continue to follow the patient for 30 days after their discontinue date. A death notification must be submitted if they expire within those 30 days. (Discontinue date = patient’s last dialysis ever).

Q: Does the transplant facility fill out the death notification if the patient returned to dialysis?

A: If the transplant failed and the patient returned to chronic outpatient dialysis, the dialysis facility is responsible for filling out the 2746 form.

Q: The patient’s transplant failed but the patient did not return to chronic outpatient dialysis before expiring. Who fills out the death notification?

A: The transplant facility is responsible for filling out the death notification if the patient did not return to chronic outpatient dialysis before expiring. In this case, please mark 15c “No” and 15d “No”.

Q: The patient was in the hospital when they died. Do I mark “other” as the modality?

A: No. Please indicate the last modality they were at your facility.

Q: The patient discontinued dialysis. How do I fill out field 13?

A: Please mark field 13 “Yes” along with one reason for discontinue (13 a-e) and fill in the last dialysis date in field 13f. The date of last dialysis treatment in field 13f must match the date of loss on the Network Patient Activity Report.

March 3, 2008

Northwest Renal Network