| 56799-0 | Address | required |
| 68997-6 | City:Loc:Pt:^Patient:Nom: | required |
| 46499-0 | State of residence | required |
| 45401-7 | Postal code | required |
| 42077-8 | Phone # | required |
| 46098-0 | Sex | required |
| 54133-4 | Ethnicity:Type:Pt:^Patient:Nom:USSG-FHT | optional |
| 68329-2 | Country of origin:Loc:Pt:^Patient:Nom: | conditional |
| 54134-2 | Race:Type:Pt:^Patient:Nom:USSG-FHT | required |
| 67884-7 | Tribal enrollment | conditional |
| 67872-2 | Medicare end stage renal disease coverage requested:Find:Pt:^Patient:Ord: | required |
| 52556-8 | Payment sources:Type:Pt:^Patient:Nom: | |
| 8302-2 | Body height | required |
| 8340-2 | Dry weight Est | required |
| 67873-0 | Cause of renal failure.primary:Type:Pt:^Patient:Nom:Reported | conditional |
| 67874-8 | Employment status - 6Mo prior to renal failure:Find:Pt:^Patient:Nom:Reported | required |
| 67875-5 | Employment status current | required |
| 67876-3 | End stage renal disease co-morbidities ICD code:Find:Pt:^Patient:Nom: | required |
| 67885-4 | Received exogenous erythropoetin or equivalent prior to end stage renal disease therapy:Find:Pt:^Patient:Ord: | conditional |
| 67886-2 | Care by nephrologist prior to end stage renal disease therapy:Find:Pt:^Patient:Ord: | conditional |
| 67887-0 | Care by kidney dietitian prior to end stage renal disease therapy:Find:Pt:^Patient:Ord: | conditional |
| 67888-8 | Vascular access for first outpatient dialysis:Type:Pt:^Patient:Nom: | conditional |
| 68449-8 | Arteriovenous fistula maturity:Find:Pt:^Patient:Ord: | conditional |
| 68450-6 | Graft maturity:Find:Pt:^Patient:Ord: | conditional |