CMS Forms List

The following provides access and/or information for many CMS forms. You may also use the "Search" feature to more quickly locate information for a specific form number or form title.

Form # Form Title Revision Date
NOTICE OF DENIAL OF MEDICAL COVERAGE/PAYMENT ("INTEGRATED DENIAL NOTICE")
2013-06-01
CMS 10036
Inpatient Rehabilitation Facility-Patient Assessment Instrument
2006-01-01
CMS 10055
SKILLED NURSING FACILITY ADVANCED BENEFICIARY NOTICE
CMS 10069
Medicare Waiver Demonstration Application
2013-12-31
CMS 10095DENC
Detailed Explanation of Non-Coverage
2006-12-01
NOTICE OF MEDICARE NON-COVERAGE
2006-12-01
CMS 10106 PDF
1-800-Medicare Authorization to Disclosure Personal Health Information
2021-12-08
CMS 10114
NATIONAL PROVIDER IDENTIFIER (NPI) APPLICATION/UPDATE FORM
2021-08-01
CMS 10123
EXPEDITED REVIEW NOTICE-NOTICE OF MEDICARE PROVIDER NON-COVERAGE
2008-02-29
CMS 10124
EXPEDITED REVIEW NOTICE-DETAILED EXPLANATION OF NON-COVERAGE
2008-02-29
CMS 10125
DME Information Form - External Infusion Pumps DME 09.03
2017-02-01
CMS 10126
DME Information Form - Enteral and Parenteral Nutrition DME 10.03
2017-02-01
CMS 10146
Notice of Denial of Medicare Prescription Drug Coverage English/Spanish
2019-01-01
CMS 10156
Retiree Drug Subsidy
2005-08-01
CMS 10164
Centers for Medicare and Medicaid Services EDI Registration Form; and EDI Enrollment Form
2019-03-25
CMS 10175
Electronic File Interchange Organization (EFIO) Certification Statement
2022-02-28
CMS 10198
Creditable Coverage Disclosure to CMS On-line Form and Instructions
2017-12-27
CMS 10221
Independent Diagnostic Testing Facilities-Site Investigation
2020-05-01
CMS 10252
DATA USE AGREEMENT (DUA) CERTFICATE OF DISPOSITION (COD) FOR DATA ACQUIRED FROM THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
2022-04-27
CMS 10269
CMN Positive Airway Pressure (PAP)Devices for Obstructive Sleep Apnea
2009-12-01
CMS 10287
Medicare Quality of Care Complaint Form
2015-11-01
CMS 10798
Application for Enrollment in Part B Immunosuppressive Drug Coverage
2023-01-31
CMS 116
CLINICAL LABORATORY IMPROVEMENT AMENDMENTS OF 1988 (CLIA) APPLICATION FOR CERTIFICATION
2020-04-01
CMS 1450
UB-04 Uniform Bill
2007-03-01
CMS 1490S
PATIENT'S REQUEST FOR MEDICAL PAYMENT (English/Spanish)
2021-06-01
CMS 1500
Health Insurance Claim Form
2012-02-01
HHA Functional Assessment Instrumental
2013-05-01
CMS 1539
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL
1984-07-01
CMS 1541B
RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN EMERGENCY CASES INVESTIGATION REPORT
2014-09-01
CMS 1557
SURVEY REPORT FORM - CLIA
2021-02-01
CMS 1561
HEALTH INSURANCE BENEFIT AGREEMENT
2001-07-01
CMS 1561A
HEALTH INSURANCE BENEFIT AGREEMENT-RURAL HEALTH CLINIC
2002-04-01
CMS 1563
Monthly Intermediary Report on Medicare Secondary Payer Savings
1997-11-01
CMS 1564
MONTHLY CARRIER REPORT ON MEDICARE SECONDARY PAYER SAVINGS
1997-11-01
CMS 1572
HHA SURVEY REPORT
2022-07-01
CMS 1592
SMI PREMIUM ACCTG FORM
1986-07-01
CMS 1666
REGIONAL OFFICE REQUEST FOR ADDITIONAL INFORMATION
1980-04-01
CMS 1696
APPOINTMENT OF REPRESENTATIVE
2021-09-01
CMS 1728
HOME HEALTH AGENCY COST REPORT
2001-06-01
CMS 1763
Request for Termination of Premium Hospital Insurance of Supplementary Medical Insurance
2022-01-31
CMS 1771
ATTENDING PHYSICIANS STATEMENT AND DOCUMENTATION FOR MEDICARE EMERGENCY
1977-09-01
CMS 179
TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL
1992-07-01
CMS 18-F-5
APPLICATION FOR PART A (HOSPITAL INSURANCE)
2023-02-28
CMS 1856
Request for Certification in the Medicare and/or Medicaid Program to Provide Outpatient Physical Therapy and/or Speech Pathology Services
2006-12-11
CMS 1880
REQUEST FOR CERTIFICATION AS SUPPLIER OF PORTABLE XRAY SERVICES
2018-05-31
CMS 1882
PORTABLE XRAY SURVEY REPORT
2009-02-01
CMS 1957
SSO REPORT OF STATE BUY IN PROBLEM
2018-04-01
CMS 1960
REQUEST FOR EVIDENCE OF MEDICAL NECESSITY
1969-05-01
CMS 1980
CARRIER OR INTERMEDIARY REQUEST FOR SSO ASSISTANCE
1978-03-01
CMS 1984
HOSPICE COST REPORT
2005-02-01
CMS 20017
ADVISORY PANEL ON HOSPITAL OUTPATIENT PAYMENT
2017-04-01
CMS 20027
MEDICARE REDETERMINATION REQUEST FORM
0019-07-01
CMS 20031
TRANSFER (ASSIGNMENT) OF APPEAL RIGHTS
2018-03-01
CMS 20033
MEDICARE RECONSIDERATION REQUEST FORM
0019-07-01
CMS 20034A/B
REQUEST FOR MEDICARE HEARING BY AN ADMINISTRATIVE LAW JUDGE
2015-03-01
CMS 20037
APPLICATION FOR ACCESS TO CMS COMPUTER SYSTEMS
2010-06-01
CMS 20040
Regional Office Meeting/Speaker Request Form
0005-12-01
CMS 20041
Speech Invitation Request Background Information
0005-12-01
CMS 20056
Medicare Adminstration Observation
2013-02-01
CMS 2007
PROVIDER TIE IN NOTICE
1982-03-01
CMS 20134
Medicare Enrollment Application - Medicare Diabetes Prevention Program (MDPP) Suppliers
2018-01-01
CMS 20143
Medicare Easy Pay Premium Statement
2021-11-01
CMS 2088-92
OUTPATIENT REHAB PROVIDER COST REPORT
2004-12-01
CMS 209
LABORATORY PERSONNEL REPORT (CLIA)
2021-01-01
CMS 216
ORGAN PROCUREMENT ORGANIZATION-HISTO-COMPATIBILITY LAB STATEMENT OF REIMBURSABLE COSTS
2005-11-01
CMS 2178
HI/SMI ENTITLEMENT PROBLEM REFERRAL
2006-09-01
CMS 222
INDEPENDENT RURAL HEALTH CLINIC WORKSHEET
2005-01-01
CMS 2384
THIRD PARTY PREMIUM BILLING REQUEST, MEDICARE
2018-03-01
CMS 2540-96
SNF AND SNF HEALTH CARE COMPLEX COST REPORT
2006-05-01
CMS 2552-96
COST REPORT FOR ELECTRONIC FILING OF HOSPITALS
2004-05-01
CMS 2567
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
2022-03-18
CMS 2567B
POST-CERTIFICATION REVISIT REPORT
1992-09-01
CMS 265
INDEPENDENT RENAL DIALYSIS FACILITY COST REPORT
2005-03-01
CMS 2690
REQ FOR CANCELLATION OF SMI
1978-03-01
CMS 2728
ESRD MEDICAL EVIDENCE REPORT MEDICARE ENTITLEMENT AND/OR PATIENT REGISTRATION
2006-03-01
CMS 2744A
ESRD FACILITY SURVEY (DIALYSIS UNIT ONLY)
2020-07-01
CMS 2744B
END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM ESRD FACILITY SURVEY (TRANSPLANT CENTERS ONLY)
2020-07-01
CMS 2746
ESRD DEATH NOTIFICATION
2006-08-01
CMS 2786M
Worksheet for Determining Evacuation Capability - ICF-IID (Existing Facilities Only) 2012 Life Safety Code
2018-07-01
CMS 2786R
Fire Safety Survey Report - Health Care 2012 Life Safety Code
2018-07-01
CMS 2786T
Fire Safety Evaluation System - Health Care 2012 Life Safety Code
2022-10-01
CMS 2786U
Fire Safety Survey Report - ASC & ESRD 2012 Life Safety Code
2018-07-01
CMS 2786V
Fire Safety Survey Report - ICF-IID (Small Facilities) 2012 Life Safety Code
2018-07-01
CMS 2786W
Fire Safety Survey Report - ICF-IID (Large Facilities) 2012 Life Safety Code
2018-07-01
CMS 2786X
Fire Safety Survey Report - ICF-IID (Apartment House) 2012 Life Safety Code
2018-07-01
CMS 2786Y
Fire Safety Evaluation System - ICF-IID (Small Facilities) 2012 Life Safety Code
2018-07-01
CMS 2802
REQUEST FOR VALIDATION OF ACCREDITATION
2011-02-01
CMS 2802B
REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR HOSPICE
2011-02-01
CMS 2802C
REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR HOME HEALTH AGENCY
2019-03-31
CMS 2802D
REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR AMBULATORY SURGICAL CENTER
2011-02-01
CMS 2802E
REQUEST FOR VALIDATION OF ACCREDITATION FOR CRITICAL ACCESS HOSPITAL SURVEY
2011-02-01
CMS 2802F
Authorization for State Agency Psychiatric Hospital Validation Survey
2011-11-01
CMS 287
HOME OFFICE COST STATEMENT
1995-11-01
CMS 2878
ACCREDITED HOSPITAL ALLEGATIONS REPORT
1986-04-01
CMS 29
VERIFICATION OF CLINIC DATA ? RURAL HEALTH CLINIC PROGRAM
2022-06-01
CMS 3070G
ICF/IID Survey Report
2013-03-01
CMS 3070H
ICF/IID Deficiencies Report
2013-03-01
CMS 3070I
INDIVIDUAL OBSERVATION WORKSHEET
1995-10-01
CMS 339
PROVIDER COST REPORT REIMBURSEMENT QUESTIONNAIRE
2006-04-30
CMS 3509
ALJ MEDICARE CASE FOLDER (CMS)
2002-08-02
CMS 359
CORF REPORT FOR CERTIFICATION TO PARTICIPATE IN MEDICARE
2021-04-01
CMS 36
CONSENT FOR HOME VISIT (English/Spanish)
1990-12-01
CMS 360
COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY SURVEY REPORT
2021-03-31
CMS 36P
CONSENT FOR HOME VISIT FOR PACE SERVICES EVALUATION
2002-07-01
CMS 370
HEALTH INSURANCE BENEFITS AGREEMENT-AMBULATORY SURGICAL CENTER
2002-04-01
CMS 377
AMBULATORY SURGICAL CENTER REQUEST FOR CERTIFICATION IN MEDICARE
0021-02-28
CMS 379
FINANCIAL STATEMENT OF DEBTOR
2007-07-01
CMS 381
MODEL LETTER REQUESTING IDENTIFICATION OF EXTENSION LOCATIONS
2005-12-01
CMS 383
HEALTH INSURANCE CASE SUMMARY
1982-12-01
CMS 384
QIO CASE SUMMARY
1992-03-01
CMS 4040
REQUEST FOR ENROLLMENT IN SUPPLEMENTARY MEDICAL INSURANCE (English / Spanish)
2020-08-01
CMS 40B
Application for Enrollment in Medicare - Part B (Medical Insurance)
2021-07-31
CMS 416
Early ad Periodic Screening Diagnostic and Treatment Participation Report
1999-06-01
CMS 417
HOSPICE REQUEST FOR CERTIFICATION IN MEDICARE
2021-11-30
CMS 43
APPLICATION FOR HOSPITAL INSURANCE BENEFITS FOR INDIVIDUALS WITH END STAGE RENAL DISEASE
2023-02-28
CMS 437
PSYCHIATRIC UNIT CRITERIA WORKSHEET
2006-04-01
CMS 437A
REHAB UNIT CRITERIA WORKSHEET
2015-07-28
CMS 437B
REHAB HOSPITAL CRITERIA WORKSHEET
2015-07-28
CMS 460
MEDICARE PARTICIPATING PHYSICIAN OR SUPPLIER AGREEMENT
2022-11-01
CMS 462L
ADVERSE ACTI0N EXTRACT FOR SNFs AND NFs
1995-07-01
CMS 484
CERTIFICATE OF MEDICAL NECESSITY - Oxygen DME 484.5
2017-02-01
CMS 500
MEDICARE PREMIUM BILL
2021-11-01
CMS 5011A-B
REQUEST FOR MEDICARE HEARING BY ADMINISTRATIVE LAW JUDGE
2017-01-01
CMS 576
Organ Procurement Request for Designation as an OPO
1993-01-01
CMS 576A
Health Insurance Benefits Agreement with Organ Procurement Organization
2006-06-30
CMS 588
Electronic Funds Transfer (EFT) Authorization Agreement
2020-12-01
CMS 632FOI
FREEDOM OF INFORMATION ACT REQUEST
2013-03-01
CMS 633
Invoice of Fees for FOIA Services
2008-01-01
Hospice Survey AND Deficiencies Report
2008-06-01
CMS 671
LTC Facility Application for Medicare/Medicaid
2018-09-01
CMS 672
Resident Census and Conditions of Residents
2012-05-01
CMS 724
Medicare/Medicaid Psychiatric Hospital Survey Data
1994-09-01
CMS 725
Surveyor Worksheet for Psychiatric Hospital Review:Two Special Conditions
1994-09-01
CMS 726
CMS Death Record Review Data Sheet
1994-09-01
CMS 727
CMS Nursing Complement Data
1994-09-01
CMS 728
CMS Staff Data
1994-09-01
CMS 729
Data Collection Medical Staff Coverage
1994-09-01
CMS 801
Offsite Survey Prep Worksheet
1995-07-01
CMS 802
Roster/Sample Matrix
2022-10-24
CMS 807
Surveyor Notes Worksheet
1995-07-01
CMS 820
IN-CENTER HEMODIALYSIS (HD) CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2005
2005-01-01
CMS 821
PERITONEAL DIALYSIS CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2005
2005-01-01
CMS 838
Medicare Credit Balance Reporting Requirements
2003-10-01
CMS 846
Certificate of Medical Necessity - Pneumatic Compression Devices DME 04.04B
2017-02-01
CMS 847
Certificate of Medical Necessity - Osteogenesis Stimulators - DME 04.04C
2017-02-01
CMS 848
Certificate of Medical Necessity - Transcutaneous Electrical Nerve Stimulator (TENS) - DME 06.03B
2017-02-01
CMS 849
Certificate of Medical Necessity - Seat Lift Mechanisms - DME 07.03A
2017-02-01
CMS 854
Certificate of Medical Necessity - DME 11.02
2017-02-02
CMS 855A
Medicare Enrollment Application - Institutional Providers
2011-07-01
CMS 855B
Medicare Enrollment Application - Clinics/Group Practices and Certain Other Suppliers
2021-03-01
CMS 855I
Medicare Enrollment Application - Physicians and Non-Physician Practitioners
2018-12-01
CMS 855O
Medicare Enrollment Application - Registration For Eligible Ordering and Referring Physicians and Non-Physician Practitioners
2022-07-01
CMS 855R
Medicare Enrollment Application - Reassignment of Medicare Benefits
2020-01-01
CMS 855S
Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers
2022-01-01
CMS L457
ACKNOWLEDGMENT OF REQUEST FOR MEDICARE MEDICAL INSURANCE TERMINATION
2003-02-01
CMS L458
ACKNOWLEDGMENT OF REQUEST FOR PREMIUM HOSPITAL INSURANCE TERMINATION
2003-02-01
CMS L564
REQUEST FOR EMPLOYMENT INFORMATION
2020-05-26
Addendum to Data Use Agreement (DUA)
2020-06-11
Data Use Agreement (DUA)- Limited Data Sets
2020-06-11
CMS R-0235M
Medicaid Agency Data Use Agreement
2007-07-01
CMS R-0235MA
Addendum to the Medicaid State Agency Data Use Agreement
2006-03-01
CMS R-0235MC
Compliance Plan for Accounting for Disclosures of Privacy Protected Data Released From a System of Records (SOR) Housed in a State-Located Server
2006-03-01
Data Use Agreement (DUA)- Update to Existing DUA
2020-06-11
CMS R-131
ADVANCE BENEFICIARY NOTICE (ABN)
2011-03-01
CMS R-193
IMPORTANT MESSAGE FROM MEDICARE (IM)
2010-07-01
CMS R-285
Request for Retirement Benefit Information
2023-02-28
CMS R-296
HOME HEALTH ADVANCE BENEFICIARY NOTICE
2009-08-01
CMS-10396
Medication Therapy Management Program Standardize Format
2012-01-20
CMS-10455
Report of a Hospital Death Associated with Restraint or Seclusion
2018-07-19
CMS-10797
Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances)
2022-03-31
CMS-R-0235 D1
DSH Data Use Agreement for Cost Reporting Periods Prior to those that include December 8, 2004
2009-12-01
CMS-R-0235 D2
DSH Data Use Agreement for Cost Reporting Periods that Include December 8, 2004 and therafter
2009-12-01
Page Last Modified:
05/25/2023 05:13 PM