Form 3111, End-Stage Renal Disease Evaluation

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Effective Date: 5/2017


Updated: 5/2017


Counselors must evaluate information included in this form to determine whether a consumer is eligible for services. The examining physician uses the form to provide information about dialysis, functional capabilities, transplant history, medications, and side-effects of anti-rejection medications in addition to laboratory data and current treatments.

Copies and Distribution

No copies are required. The completed form is placed in the consumer’s paper file. If the consumer’s case is submitted to the state medical consultant for guidance and/or decision about services, a copy of the form is included in the courtesy file.


The completed form is part of the consumer’s paper file and is retained until the end of the fiscal year the case is closed, plus five years.

Acronyms and Definitions

CAPD—Continuous ambulatory peritoneal dialysis

Special Instructions

This form is referenced in RPM Chapter 3: Eligibility, 3.8.2 Policy.