Forms

All Forms

1-800-MEDICARE Authorization to Disclose Personal Health Information
Accelerated Payments to Providers
Administrative Simplification Compliance Act Waiver Request Form
Advance Beneficiary Notice of Noncoverage (CMS-R-131)
Advance Payments to Providers
Applying for an Extended Repayment Schedule
Appointment of Representative Form (CMS-1696)
Children’s Hospitals Verification of Age for Eligibility
CHOPD Accelerated Payments to Providers
CHOPD Advance Payments to Providers
Clerical Error/Omission Reopening Request Form
CMS -1561 Health Insurance Benefit Agreement
CMS Forms
CMS Hospital Cost Report Forms and Instructions
CMS-1539 Medicare/Medicaid Certification and Transmittal
CMS-1561 Health Insurance Benefit Agreement
CMS-20134 Medicare Enrollment Application - Medicare Diabetes Prevention Program Suppliers
CMS-588 Electronic Funds Transfer (EFT) Authorization Agreement
CMS-855A Medicare Enrollment Application - Institutional Providers
CMS-855B Medicare Enrollment Application - Clinics/Group Practices and Certain Other Suppliers
CMS-855I Medicare Enrollment Application - Physicians and Non-Physician Practitioners
CMS-855O Medicare Enrollment Application - For Eligible Ordering and Referring Physicians and Non-Physician Practitioners
Cost Report Submission Checklist
Cover Sheet for Electronically Submitted Medical Records
Dispute Request for Assistance (RFA) Form
EDI E-mail Inquiry Form
EDI Guided Enrollment Form
Education Partnership Request Form
Education Partnership Request Form
Education Partnership Request Form
Fee-for-Service Expedited Determination Notices
Fee-for-Service Home Health Beneficiary Notice of Noncoverage
Financial Contact Information Form
Form CMS-339, Transmittal 8
HHS-690 Assurance of Compliance
Home Health Change of Care Notice (CMS-10280)
Home Health Third Party Liability Demand Bill Redetermination Request Form
Hospice Cap
Hospice PIP Rate Review Form
Immediate Recoupment Request Form – Electronic/E-mail
Interim Rate Review Documentation Request Form for Critical Access Hospitals
Interim Rate Review Documentation Request Form for Hospitals
Interim Rate Review Documentation Request Form for TEFRA Hospital/Unit
Investigational Device Exemption Requests
J6 Applying for an Extended Repayment Schedule
J6 Medicare Secondary Payer Overpayment Request Form
J6 Medicare Secondary Payer Part B Carrier Voluntary Refund Form
J6 Overpayment Recovery Unit Part B Carrier Voluntary Refund Form
J6 Part A Immediate Recoupment Request Form
J6 Part A Overpayment Recovery Unit Voluntary Refund Form
J6 Part B Applying for an Extended Repayment Schedule
J6 Part B Immediate Recoupment Request Form
JK Applying for an Extended Repayment Schedule
JK Extended Repayment Plan Request Form
JK Medicare Secondary Payer Part B Carrier Voluntary Refund Form
JK Overpayment Recovery Unit Part B Carrier Voluntary Refund Form
JK Part A Immediate Recoupment Request Form
JK Part A Overpayment Recovery Unit Voluntary Refund Form
JK Part B Immediate Recoupment Request Form
JK Part B Medicare Secondary Payer Overpayment Request Form
Jurisdiction 6 Medicare Part A MSP Overpayment Request Form
Jurisdiction 6 Medicare Part A Overpayment Request Form
Jurisdiction K Medicare Part A MSP Overpayment Request Form
Jurisdiction K Medicare Part A Overpayment Request Form
Level 1: Part A Redetermination Request Form
Level 1: Redetermination Request Form
Level 2: Reconsideration Request Form (CMS-20033)
Level 3: Request for an Administrative Law Judge Hearing or Review of Dismissal (OMHA‐100)
Level 4: Review of Hearing Decision Form (DAB-101)
Low / No Utilization Cost Report Waiver
LVAM Request Form
Medicare Correspondence Request Form
Medicare Credit Balance Report (CMS-838) Excel Spreadsheet
Medicare Credit Balance Report Form and Instructions (CMS-838)
Medicare FQHC PWK Fax/Mail Cover Sheet
Medicare Home Health and Hospice PWK Fax/Mail Cover Sheet
Medicare JK Part A PWK Fax/Mail Cover Sheet
Medicare Opt-Out Affidavit
Medicare Part A PWK Fax/Mail Cover Sheet
Medicare Part A Rebuttal Form
Medicare Part B PWK Fax/Mail/esMD Cover Sheet
Medicare Part B PWK Fax/Mail/esMD Cover Sheet
Medicare Part B Rebuttal Form
Medicare Participating Physician or Supplier Agreement Form (CMS-460)
Medicare Privacy Statement Form
Medicare Private Contract Form
Overpayment Recovery Unit FQHC Voluntary Refund Form
Prior Authorization Request for Outpatient Services: Blepharoplasty, Blepharoptosis Repair and Brow Ptosis Repair
Prior Authorization Request for Outpatient Services: Botulinum Toxin
Prior Authorization Request for Outpatient Services: Cervical Fusion
Prior Authorization Request for Outpatient Services: Facet Joint Interventions
Prior Authorization Request for Outpatient Services: Implanted Spinal Neurostimulators
Prior Authorization Request for Outpatient Services: Panniculectomy
Prior Authorization Request for Outpatient Services: Rhinoplasty
Prior Authorization Request for Outpatient Services: Vein Ablation
Prior Authorization Request for Repetitive, Scheduled Nonemergent Ambulance Transports Medicare Part B Fax/Mail Coversheet
Provider Enrollment Appeals Cover Sheet
Provider Enrollment Appeals Cover Sheet
Provider Request for PS&R Form
Provider Transaction Access Number Request Form
Reopening Request Form
Transfer of Appeal Rights
Vaccine Roster Form