| 45394-4 | Patient Last name | required |
| 45392-8 | Patient First name | required |
| 45393-6 | Middle initial | required |
| 45397-7 | Medicare or comparable # | required |
| 46098-0 | Sex | required |
| 21112-8 | Birth date | required |
| 45396-9 | Social Security # | required |
| 46499-0 | State of residence | required |
| 71480-8 | Location of death:Loc:Pt:^Patient:Nom:ESRD | required |
| 31211-6 | Date of death | required |
| 68341-7 | Dialysis at time of death:Type:Pt:^Patient:Nom: | required |
| 67878-9 | Facility name:ID:Pt:Dialysis facility:Nom: | required |
| 65833-6 | Address:Addr:Pt:Facility:Nom: | required |
| 65833-6 | Address:Addr:Pt:Facility:Nom: | |
| 65647-0 | City Fclty | required |
| 68488-6 | State:Loc:Pt:Facility:Nom: | required |
| 68330-0 | CMS certification number - CCN:ID:Pt:Dialysis facility:Nom: | required |
| 68343-3 | Cause of death.primary:Find:Pt:^Patient:Nom: | required |
| 68344-1 | Were there secondary causes of death:Find:Pt:^Patient:Ord: | required |
| 68345-8 | Cause of death.secondary:Find:Pt:^Patient:Nom: | optional |
| 68346-6 | Cause of death.other:Find:Pt:^Patient:Nom: | optional |
| 68347-4 | Renal replacement therapy discontinued prior to death:Find:Pt:^Patient:Ord: | required |
| 68348-2 | Reason renal replacement therapy discontinued:Find:Pt:^Patient:Nom: | required |
| 68349-0 | Date last dialysis treatment:Date:Pt:^Patient:Qn: | required |
| 68350-8 | Discontinuation renal replacement therapy request of patient or family:Find:Pt:^Patient:Ord: | required |
| 68351-6 | Date most recent transplant:Date:Pt:^Patient:Qn: | optional |
| 68332-6 | Donor:Type:Pt:^Patient:Nom: | optional |
| 68352-4 | Graft functioning at death:Find:Pt:^Patient:Ord: | conditional |
| 68353-2 | Did patient resume chronic maintenance dialysis prior to death:Find:Pt:^Patient:Ord: | conditional |
| 68354-0 | Hospice prior to death:Find:Pt:^Patient:Ord: | required |
| 52526-1 | Attending physician name | required |
| 68995-0 | Person completing form name:Pn:Pt:Provider:Nom: | required |
| 68355-7 | Date signed:TmStp:Pt:Form:Qn: | required |
| 65838-5 | Date submitted:Date:Pt:Form:Qn: | required |
| 68356-5 | Form version:ID:Pt:Form:Nom: | required |
| 68359-9 | End stage renal disease death notification - OMB CMS form 2746:-:Pt:^Patient:-: | |