The IRS has released a new form for estate and gift tax returns. Form CMS 2746 U3 is now available for use by taxpayers. This form is used to report certain information about generation-skipping transfers (GSTs) and should be filed by September 30th of the year following the transfer. The new form will help the IRS track GSTs and ensure that they are being properly reported. Taxpayers who have made any GSTs in the past should review the instructions for Form CMS 2746 U3 and make sure that they are reporting this information correctly. Failing to report GSTs can result in significant penalties, so it is important to understand how this form works and to file it on time.
| Question | Answer |
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| Form Name | Form Cms 2746 U3 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | 05_2746_death_n otification_200 4 death notification form |
DEPARTMENT OF HEALTH AND HUMAN SERVICES |
Form Approved |
CENTERS FOR MEDICARE & MEDICAID SERVICES |
OMB No. |
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ESRD DEATH NOTIFICATION
END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM
1. |
Patient’s Last Name |
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First |
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MI |
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2. Medicare Claim Number |
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3. |
Patient’s Sex |
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4. |
Date of Birth |
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5. |
Social Security Number |
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a. ■ Male b. ■ Female |
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_ _ / _ _ / _ _ _ _ |
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Month |
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Year |
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6. |
Patient’s State of Residence |
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7. |
Place of Death |
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8. |
Date of Death |
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a. ■ Hospital |
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c. ■ Home |
e. ■ Other |
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b. ■ Dialysis Unit |
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d. ■ Nursing Home |
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Year |
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9. |
Modality at Time of Death |
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a. ■ Incenter Hemodialysis |
b. ■ Home Hemodialysis |
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c. ■ CAPD |
d. ■ CCPD e. ■ Transplant |
f. ■ Other |
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10. |
Provider Name and Address (Street) |
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11. |
Provider Number |
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Provider Address (City/State)
12.Causes of Death (enter codes from list on back of form)
a.Primary Cause _ _ _
b.Were there secondary causes?
■No
■ Yes, specify: _ _ _ |
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_ _ _ |
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C. If cause is other (98) please specify:___________________________________________________________________ |
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13. Renal replacement therapy discontinued prior to death: |
■ Yes |
■ No 14. Was discontinuation of renal replacement |
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therapy after patient/family request to stop |
If yes, check one of the following: |
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dialysis? |
a.■ Following HD and/or PD access failure
b. ■ Following transplant failure |
■ Yes |
■ No |
c.■ Following chronic failure to thrive
d. ■ Following acute medical complication |
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■ Unknown |
■ Not Applicable |
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e. |
■ Other |
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f. |
Date of last dialysis treatment |
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15. If deceased ever received a transplant: |
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16. |
Was patient receiving Hospice care prior |
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a. Date of most recent transplant |
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■ Unknown |
to death? |
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b. Type of transplant received |
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■ Living Related |
■ Living Unrelated |
■ Deceased |
■ Unknown |
■ Yes |
■ No |
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c. Was graft functioning (patient not on dialysis) at time of death? |
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■ Unknown |
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■ Yes |
■ No |
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■ Unknown |
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d. Did transplant patient resume chronic maintenance dialysis prior to death? |
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■ Yes |
■ No |
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■ Unknown |
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17. Name of Physician (Please print complete name)
18. Signature of Person Completing This Form
Date
This report is required by law (42, U.S.C. 426; 20 CFR 405, Section 2133). Individually identifiable patient information will not be disclosed except as provided for in the Privacy Act of 1974 (5 U.S.C. 5520; 45 CFR Part 5a).
Form
ESRD DEATH NOTIFICATION FORM
LIST OF CAUSES
CARDIAC
23 Myocardial infarction, acute
25Pericarditis, incl. Cardiac tamponade
26Atherosclerotic heart disease
27Cardiomyopathy
28Cardiac arrhythmia
29Cardiac arrest, cause unknown
30Valvular heart disease
31Pulmonary edema due to exogenous fluid
32Congestive Heart Failure
VASCULAR
35Pulmonary embolus
36Cerebrovascular accident including intracranial hemorrhage
37Ischemic brain damage/Anoxic encephalopathy
38Hemorrhage from transplant site
39Hemorrhage from vascular access
40Hemorrhage from dialysis circuit
41Hemorrhage from ruptured vascular aneurysm
42Hemorrhage from surgery (not 38, 39, or 41)
43Other hemorrhage (not
44Mesenteric infarction/ischemic bowel
INFECTION
33Septicemia due to internal vascular access
34Septicemia due to vascular access catheter
45Peritoneal access infectious complication, bacterial
46Peritoneal access infectious complication, fungal
47Peritonitis (complication of peritoneal dialysis)
48Central nervous system infection (brain abscess, meningitis, encephalitis, etc.)
51Septicemia due to peripheral vascular disease, gangrene
52Septicemia, other
61Cardiac infection (endocarditis)
62Pulmonary infection (pneumonia, influenza)
63Abdominal infection (peritonitis (not comp of PD),
perforated bowel, diverticular disease, gallbladder)
70
LIVER DISEASE
64Hepatitis B
71Hepatitis C
65Other viral hepatitis
66
67Cirrhosis
68Polycystic liver disease
69Liver failure, cause unknown or other
72
73Pancreatitis
75Perforation of peptic ulcer
76Perforation of bowel (not 75)
METABOLIC
24Hyperkalemia
77Hypokalemia
78Hypernatremia
79Hyponatremia
100Hypoglycemia
101Hyperglycemia
102Diabetic coma
95Acidosis
ENDOCRINE
96Adrenal insufficiency
97Hypothyroidism
103 Hyperthyroidism
OTHER
80Bone marrow depression
81Cachexia/failure to thrive
82Malignant disease, patient ever on Immunosuppressive therapy
83Malignant disease (not 82)
84Dementia, incl. dialysis dementia, Alzheimer's
85Seizures
87Chronic obstructive lung disease (COPD)
88Complications of surgery
89Air embolism
104Withdrawal from dialysis/uremia
90Accident related to treatment
91Accident unrelated to treatment
92Suicide
93Drug overdose (street drugs)
94Drug overdose (not 92 or 93)
98Other cause of death
99Unknown
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