CMS Forms List https://www.cms.gov/rss/31831 Sun, 08 Mar 2026 07:10:42 -0400 Centers for Medicare and Medicaid ServicesCMS 10883Fri, 16 Aug 2024 11:43:10 -0400https://www.cms.gov//medicare/forms-notices/cms-forms-list/cms-10883https://www.cms.gov//medicare/forms-notices/cms-forms-list/cms-10883title: ADA Dental Claim Form

]]>CMS10797Wed, 04 Jan 2023 15:17:07 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-list/cms10797https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-list/cms10797omb_number: 0938-1426

revision_date: Tue, 01 Jul 2025 00:00:00 -0400

special_instructions: Use this form to enroll in Medicare Part A (Hospital Insurance) or Part B (Medical Insurance) during a Special Enrollment Period due to exceptional circumstances such as natural disasters, loss of Medicaid coverage, or release from incarceration. You must provide written proof of circumstances beyond your control that prevented enrollment during your Initial Enrollment Period. Submit your completed and signed form by mail, fax, or by visiting your local Social Security office in person. Contact Social Security at 1-800-772-1213 (TTY 1-800-325-0778) with questions.

title: Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances)

]]>CMS 10798Thu, 10 Nov 2022 11:21:35 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-list/cms-10798https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-list/cms-10798omb_number: 0938-1428

revision_date: Wed, 01 Feb 2023 00:00:00 -0500

special_instructions: N/A

title: Application for Enrollment in Part B Immunosuppressive Drug Coverage

]]>CMS 10175Wed, 27 Apr 2022 11:47:09 -0400https://www.cms.gov//httpswwwcmsgovmedicarecms-formscms-formscms-forms-list/cms-10175https://www.cms.gov//httpswwwcmsgovmedicarecms-formscms-formscms-forms-list/cms-10175title: Electronic File Interchange Organization (EFIO) Certification Statement

]]>Medicare Easy Pay Premium StatementMon, 11 Apr 2022 14:57:40 -0400https://www.cms.gov//httpscmsgovmedicarecms-formscms-formscms-forms-list/medicare-easy-pay-premium-statementhttps://www.cms.gov//httpscmsgovmedicarecms-formscms-formscms-forms-list/medicare-easy-pay-premium-statementtitle: Medicare Easy Pay Premium Statement

]]>COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY SURVEY REPORTWed, 14 Apr 2021 09:46:29 -0400https://www.cms.gov//medicarecms-formscms-formscms-forms-list/comprehensive-outpatient-rehabilitation-facility-survey-report-0https://www.cms.gov//medicarecms-formscms-formscms-forms-list/comprehensive-outpatient-rehabilitation-facility-survey-report-0title: COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY SURVEY REPORT

]]>CMS 20134Mon, 04 Nov 2019 02:44:32 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms20134https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms20134revision_date: Mon, 01 Dec 2025 12:00:00 -0500

special_instructions: N/A

title: Medicare Enrollment Application - Medicare Diabetes Prevention Program (MDPP) Suppliers

]]>CMS 20056Mon, 04 Nov 2019 02:37:56 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms20056https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms20056omb_number: Exempt

revision_date: Fri, 01 Feb 2013 12:00:00 -0500

special_instructions: N/A

title: Medicare Adminstration Observation

]]>CMS-10455Mon, 04 Nov 2019 02:37:13 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms10455https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms10455title: Report of a Hospital Death Associated with Restraint or Seclusion

]]>CMS 20037Mon, 04 Nov 2019 02:35:32 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms20037https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms20037omb_number: Exempt

revision_date: Tue, 01 Jun 2010 12:00:00 -0400

special_instructions: N/A

title: APPLICATION FOR ACCESS TO CMS COMPUTER SYSTEMS

]]>CMS-R-0235 D1Mon, 04 Nov 2019 02:31:09 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms054015https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms054015title: DSH Data Use Agreement for Cost Reporting Periods Prior to those that include December 8, 2004

]]>CMS-10396Mon, 04 Nov 2019 02:31:09 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms10396https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms10396title: Medication Therapy Management Program Standardize Format

]]>CMS-R-0235 D2Mon, 04 Nov 2019 02:31:07 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms055728https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms055728title: DSH Data Use Agreement for Cost Reporting Periods that Include December 8, 2004 and therafter

]]>CMS 437BMon, 04 Nov 2019 02:06:50 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006760https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006760omb_number: 0938-0986

revision_date: Wed, 30 Sep 2026 12:00:00 -0400

special_instructions: N/A

title: REHAB HOSPITAL CRITERIA WORKSHEET

]]>CMS 1572Mon, 04 Nov 2019 02:06:50 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms012203https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms012203omb_number: 0938-0355

revision_date: Fri, 01 Jul 2022 12:00:00 -0400

special_instructions: N/A

title: HHA SURVEY REPORT

]]>CMS 1450Mon, 04 Nov 2019 02:06:49 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1196256https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1196256omb_number: 0938-0997

revision_date: Thu, 01 Mar 2007 12:00:00 -0500

special_instructions: Instructions on where/how to obtain the Form 1450 can be obtained from the provider’s servicing Medicare Administrative Contractor (MAC).

title: UB-04 Uniform Bill

]]>CMS 10095NOMNCMon, 04 Nov 2019 02:06:49 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms020275https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms020275omb_number: 0938-0910

revision_date: Fri, 01 Dec 2006 12:00:00 -0500

special_instructions: N/A

title: NOTICE OF MEDICARE NON-COVERAGE

]]>CMS 10069Mon, 04 Nov 2019 02:06:49 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1189117https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1189117omb_number: 0938-0880

revision_date: Tue, 31 Dec 2013 12:00:00 -0500

special_instructions: N/A

title: Medicare Waiver Demonstration Application

]]>CMS 2786TMon, 04 Nov 2019 02:06:48 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms009393https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms009393omb_number: Exempt

revision_date: Sun, 01 Feb 2026 12:20:00 -0500

special_instructions: N/A

title: Fire Safety Evaluation System - Health Care 2012 Life Safety Code

]]>CMS 2786MMon, 04 Nov 2019 02:06:48 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008870https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008870omb_number: Exempt

revision_date: Sun, 01 Jul 2018 12:00:00 -0400

special_instructions: N/A

title: Worksheet for Determining Evacuation Capability - ICF-IID (Existing Facilities Only) 2012 Life Safety Code

]]>CMS 3070HMon, 04 Nov 2019 02:06:48 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008818https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008818omb_number: 0938-0062

revision_date: Fri, 01 Mar 2013 12:00:00 -0500

special_instructions: N/A

title: ICF/IID Deficiencies Report

]]>CMS 370Mon, 04 Nov 2019 02:06:48 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008717https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008717omb_number: 0938-0266

revision_date: Thu, 21 Nov 2024 12:00:00 -0500

special_instructions: N/A

title: HEALTH INSURANCE BENEFITS AGREEMENT-AMBULATORY SURGICAL CENTER

]]>CMS 2802EMon, 04 Nov 2019 02:06:48 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms009532https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms009532omb_number: EXEMPT

revision_date: Tue, 01 Feb 2011 12:00:00 -0500

special_instructions: N/A

title: REQUEST FOR VALIDATION OF ACCREDITATION FOR CRITICAL ACCESS HOSPITAL SURVEY

]]>CMS 848Mon, 04 Nov 2019 02:06:48 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006684https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006684omb_number: 0938-0679

revision_date: Wed, 01 Feb 2017 12:00:00 -0500

special_instructions: This form must be used starting January 1, 2007.

title: Certificate of Medical Necessity - Transcutaneous Electrical Nerve Stimulator (TENS) - DME 06.03B

]]>CMS 728Mon, 04 Nov 2019 02:06:42 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006613https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006613omb_number: 0938-0378

revision_date: Thu, 01 Sep 1994 12:00:00 -0400

special_instructions: N/A

title: CMS Staff Data

]]>CMS 2088-92Mon, 04 Nov 2019 02:06:42 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019497https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019497omb_number: 0938-0037

revision_date: Wed, 01 Dec 2004 12:00:00 -0500

special_instructions: N/A

title: OUTPATIENT REHAB PROVIDER COST REPORT

]]>CMS 643 (28 KB)Mon, 04 Nov 2019 02:06:42 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006388https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006388omb_number: 0938-0379

revision_date: Sun, 01 Jun 2008 12:00:00 -0400

special_instructions: N/A

title: Hospice Survey AND Deficiencies Report

]]>CMS 2786YMon, 04 Nov 2019 02:06:42 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms009403https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms009403omb_number: Exempt

revision_date: Sun, 01 Jul 2018 12:00:00 -0400

special_instructions: N/A

title: Fire Safety Evaluation System - ICF-IID (Small Facilities) 2012 Life Safety Code

]]>CMS 2690Mon, 04 Nov 2019 02:06:41 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms017358https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms017358revision_date: Wed, 01 Mar 1978 12:00:00 -0500

special_instructions: You must either visit or contact the Social Security Administration to obtain this form. 1-800-772-1213

title: REQ FOR CANCELLATION OF SMI

]]>CMS 820Mon, 04 Nov 2019 02:06:41 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019468https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019468omb_number: EXEMPT

revision_date: Sat, 01 Jan 2005 12:00:00 -0500

special_instructions: N/A

title: IN-CENTER HEMODIALYSIS (HD) CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2005

]]>CMS 339Mon, 04 Nov 2019 02:06:41 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019462https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019462omb_number: 0938-0301

revision_date: Sun, 30 Apr 2006 12:00:00 -0400

special_instructions: N/A

title: PROVIDER COST REPORT REIMBURSEMENT QUESTIONNAIRE

]]>CMS 2178Mon, 04 Nov 2019 02:06:41 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms017356https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms017356omb_number: EXEMPT

revision_date: Fri, 01 Sep 2006 12:00:00 -0400

special_instructions: You must either visit or contact the Social Security Administration to obtain this form. 1-800-772-1213

title: HI/SMI ENTITLEMENT PROBLEM REFERRAL

]]>CMS 36Mon, 04 Nov 2019 02:06:41 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008682https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008682omb_number: EXEMPT

revision_date: Sat, 01 Dec 1990 12:00:00 -0500

special_instructions: N/A

title: CONSENT FOR HOME VISIT (English/Spanish)

]]>CMS 1980Mon, 04 Nov 2019 02:06:41 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms013110https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms013110omb_number: EXEMPT

revision_date: Wed, 01 Mar 1978 12:00:00 -0500

special_instructions: N/A

title: CARRIER OR INTERMEDIARY REQUEST FOR SSO ASSISTANCE

]]>CMS 1564Mon, 04 Nov 2019 02:06:41 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms013079https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms013079omb_number: EXEMPT

revision_date: Sat, 01 Nov 1997 12:00:00 -0500

special_instructions: N/A

title: MONTHLY CARRIER REPORT ON MEDICARE SECONDARY PAYER SAVINGS

]]>CMS 1515A-OBSOLETEMon, 04 Nov 2019 02:06:33 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms049121https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms049121revision_date: Wed, 01 May 2013 12:00:00 -0400

special_instructions: CMS 1515 A-F forms are all obsolete. Please see related links to get information on the new worksheets.

title: HHA Functional Assessment Instrumental

]]>CMS R-0235A (35 KB)Mon, 04 Nov 2019 02:06:33 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms045942https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms045942omb_number: 0938-0734

revision_date: Thu, 11 Jun 2020 12:00:00 -0400

special_instructions: N/A

title: Addendum to Data Use Agreement (DUA)

]]>CMS 855SMon, 04 Nov 2019 02:06:32 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019480https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019480omb_number: 0938-1056

revision_date: Fri, 01 Dec 2023 12:00:00 -0500

special_instructions: N/A

title: Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers

]]>CMS 854Mon, 04 Nov 2019 02:06:32 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006700https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006700omb_number: 0938-0679

revision_date: Thu, 02 Feb 2017 12:00:00 -0500

special_instructions: This form must be used starting January 1, 2007.

title: Certificate of Medical Necessity - DME 11.02

]]>CMS R-0235U (48 KB)Mon, 04 Nov 2019 02:06:32 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms045948https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms045948omb_number: 0938-0734

revision_date: Thu, 11 Jun 2020 12:00:00 -0400

special_instructions: N/A

title: Data Use Agreement (DUA)- Update to Existing DUA

]]>CMS 2802FMon, 04 Nov 2019 02:06:32 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1254389https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1254389omb_number: Exempt

revision_date: Tue, 01 Nov 2011 12:00:00 -0400

special_instructions: N/A

title: Authorization for State Agency Psychiatric Hospital Validation Survey

]]>CMS 10095DENCMon, 04 Nov 2019 02:06:32 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1207289https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1207289omb_number: 0938-0910

revision_date: Fri, 01 Dec 2006 12:00:00 -0500

special_instructions: N/A

title: Detailed Explanation of Non-Coverage

]]>CMS R-296Mon, 04 Nov 2019 02:06:32 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms009548https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms009548omb_number: 0938-0781

revision_date: Sat, 01 Aug 2009 12:00:00 -0400

special_instructions: N/A

title: HOME HEALTH ADVANCE BENEFICIARY NOTICE

]]>CMS 10164Mon, 04 Nov 2019 02:06:32 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1215291https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1215291omb_number: 0938-0983

revision_date: Mon, 26 Aug 2024 12:00:00 -0400

special_instructions: N/A

title: Centers for Medicare and Medicaid Services EDI Registration Form; and EDI Enrollment Form

]]>CMS 2744BMon, 04 Nov 2019 02:06:32 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms020293https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms020293omb_number: 0938-0447

revision_date: Mon, 01 Sep 2025 12:00:00 -0400

special_instructions: To obtain copies of these forms, please contact your End Stage Renal Disease (ESRD) Network (see link below)

title: END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM ESRD FACILITY SURVEY (TRANSPLANT CENTERS ONLY)

]]>CMS 437Mon, 04 Nov 2019 02:06:32 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006712https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006712omb_number: 0938-0358

revision_date: Wed, 30 Sep 2026 12:00:00 -0400

special_instructions: N/A

title: PSYCHIATRIC UNIT CRITERIA WORKSHEET

]]>CMS 381Mon, 04 Nov 2019 02:06:32 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008787https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008787omb_number: 0938-0273

revision_date: Thu, 01 Aug 2024 12:00:00 -0400

special_instructions: N/A

title: MODEL LETTER REQUESTING IDENTIFICATION OF EXTENSION LOCATIONS

]]>CMS 2728Mon, 04 Nov 2019 02:06:32 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008867https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008867omb_number: 0938-0046

revision_date: Sun, 01 Jun 2025 12:00:00 -0400

special_instructions: Contact your local Social Security Office for copies of this form

title: ESRD MEDICAL EVIDENCE REPORT MEDICARE ENTITLEMENT AND/OR PATIENT REGISTRATION

]]>CMS 2746Mon, 04 Nov 2019 02:06:32 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008869https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008869omb_number: 0938-0448

revision_date: Sun, 01 Jun 2025 12:00:00 -0400

special_instructions: To obtain copies of these forms, please contact your End Stage Renal Disease (ESRD) Network (see link below)

title: ESRD DEATH NOTIFICATION

]]>CMS 855AMon, 04 Nov 2019 02:06:32 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019475https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019475omb_number: 0938-0685

revision_date: Sun, 01 Sep 2024 12:00:00 -0400

special_instructions: N/A

title: Medicare Enrollment Application - Institutional Providers

]]>CMS 855IMon, 04 Nov 2019 02:06:32 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019477https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019477omb_number: 0938-1355

revision_date: Mon, 01 May 2023 12:00:00 -0400

special_instructions: N/A

title: Medicare Enrollment Application - Physicians and Non-Physician Practitioners

]]>CMS 855OMon, 04 Nov 2019 02:06:32 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1249384https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1249384omb_number: 0938-1135

revision_date: Fri, 01 Sep 2023 12:00:00 -0400

special_instructions: N/A

title: Medicare Enrollment Application - Registration For Eligible Ordering and Referring Physicians and Non-Physician Practitioners

]]>CMS 1856Mon, 04 Nov 2019 02:06:32 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms012215https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms012215omb_number: 0938-0065

revision_date: Mon, 11 Dec 2006 12:00:00 -0500

special_instructions: DISCONTINUED FORM

title: Request for Certification in the Medicare and/or Medicaid Program to Provide Outpatient Physical Therapy and/or Speech Pathology Services

]]>CMS R-0235MCMon, 04 Nov 2019 02:06:31 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms060976https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms060976omb_number: 0938-0734

revision_date: Wed, 01 Mar 2006 12:00:00 -0500

special_instructions: N/A

title: Compliance Plan for Accounting for Disclosures of Privacy Protected Data Released From a System of Records (SOR) Housed in a State-Located Server

]]>CMS R-0235MMon, 04 Nov 2019 02:06:31 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms057233https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms057233omb_number: 0938-0734

revision_date: Sun, 01 Jul 2007 12:00:00 -0400

special_instructions: N/A

title: Medicaid Agency Data Use Agreement

]]>CMS 10146Mon, 04 Nov 2019 02:06:31 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms056137https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms056137omb_number: 0938-0976

revision_date: Tue, 01 Jan 2019 12:00:00 -0500

special_instructions: N/A

title: Notice of Denial of Medicare Prescription Drug Coverage English/Spanish

]]>CMS R-0235MAMon, 04 Nov 2019 02:06:31 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms057714https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms057714omb_number: 0938-0734

revision_date: Wed, 01 Mar 2006 12:00:00 -0500

special_instructions: N/A

title: Addendum to the Medicaid State Agency Data Use Agreement

]]>CMS 10126Mon, 04 Nov 2019 02:06:31 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1184635https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1184635omb_number: 0938-0679

revision_date: Wed, 01 Feb 2017 12:00:00 -0500

special_instructions: This form must be used starting January 1, 2007.

title: DME Information Form - Enteral and Parenteral Nutrition DME 10.03

]]>CMS 1957Mon, 04 Nov 2019 02:06:31 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms017354https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms017354title: SSO REPORT OF STATE BUY IN PROBLEM

]]>CMS 10003-NDMCPMon, 04 Nov 2019 02:06:31 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms012237https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms012237omb_number: 0938-0829

revision_date: Sat, 01 Jun 2013 12:00:00 -0400

special_instructions: N/A

title: NOTICE OF DENIAL OF MEDICAL COVERAGE/PAYMENT ("INTEGRATED DENIAL NOTICE")

]]>CMS 10124Mon, 04 Nov 2019 02:06:31 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019520https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019520omb_number: 0938-0953

revision_date: Fri, 29 Feb 2008 12:00:00 -0500

special_instructions: N/A

title: EXPEDITED REVIEW NOTICE-DETAILED EXPLANATION OF NON-COVERAGE

]]>CMS 855BMon, 04 Nov 2019 02:06:31 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019476https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019476omb_number: 0938-1377

revision_date: Mon, 01 Mar 2021 12:00:00 -0500

special_instructions: N/A

title: Medicare Enrollment Application - Clinics/Group Practices and Certain Other Suppliers

]]>CMS 209Mon, 04 Nov 2019 02:06:31 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008840https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008840omb_number: 0938-0151

revision_date: Mon, 01 Sep 2025 12:00:00 -0400

special_instructions: N/A

title: LABORATORY PERSONNEL REPORT (CLIA)

]]>CMS 377Mon, 04 Nov 2019 02:06:30 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008718https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008718omb_number: 0938-0266

revision_date: Thu, 21 Nov 2024 12:00:00 -0500

special_instructions: N/A

title: AMBULATORY SURGICAL CENTER REQUEST FOR CERTIFICATION IN MEDICARE

]]>CMS 10125Mon, 04 Nov 2019 02:06:30 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1184634https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1184634omb_number: 0938-0679

revision_date: Wed, 01 Feb 2017 12:00:00 -0500

special_instructions: This form must be used starting January 1, 2007.

title: DME Information Form - External Infusion Pumps DME 09.03

]]>CMS 437AMon, 04 Nov 2019 02:06:30 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006741https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006741omb_number: 0938-0986

revision_date: Wed, 30 Sep 2026 12:00:00 -0400

special_instructions: N/A

title: REHAB UNIT CRITERIA WORKSHEET

]]>CMS 10123Mon, 04 Nov 2019 02:06:30 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019517https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019517omb_number: 0938-0953

revision_date: Fri, 29 Feb 2008 12:00:00 -0500

special_instructions: N/A

title: EXPEDITED REVIEW NOTICE-NOTICE OF MEDICARE PROVIDER NON-COVERAGE

]]>CMS 849Mon, 04 Nov 2019 02:06:30 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006687https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006687omb_number: 0938-0679

revision_date: Wed, 01 Feb 2017 12:00:00 -0500

special_instructions: This form must be used starting January 1, 2007.

title: Certificate of Medical Necessity - Seat Lift Mechanisms - DME 07.03A

]]>CMS 3070GMon, 04 Nov 2019 02:06:30 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008815https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008815omb_number: 0938-0062

revision_date: Fri, 01 Mar 2013 12:00:00 -0500

special_instructions: N/A

title: ICF/IID Survey Report

]]>CMS 847Mon, 04 Nov 2019 02:06:30 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006677https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006677omb_number: 0938-0679

revision_date: Wed, 01 Feb 2017 12:00:00 -0500

special_instructions: This form must be used starting January 1, 2007.

title: Certificate of Medical Necessity - Osteogenesis Stimulators - DME 04.04C

]]>CMS 1763Mon, 04 Nov 2019 02:06:30 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms017353https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms017353omb_number: 0938-0025

revision_date: Mon, 31 Jan 2022 12:00:00 -0500

special_instructions: N/A

title: Request for Termination of Premium Hospital Insurance of Supplementary Medical Insurance

]]>CMS 10287Mon, 04 Nov 2019 02:06:30 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1240839https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1240839omb_number: OMB Exmpt

revision_date: Sun, 01 Nov 2015 12:00:00 -0500

special_instructions: Please refer to the document titled, QIO Contact Information in the download section to obtain the contact information for your QIO. The document includes the name, address, phone number and email address for each QIO.

title: Medicare Quality of Care Complaint Form

]]>CMS 2567Mon, 04 Nov 2019 02:06:28 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008860https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008860omb_number: 0938-0391

revision_date: Fri, 18 Mar 2022 12:00:00 -0400

special_instructions: N/A

title: STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

]]>CMS 10269Mon, 04 Nov 2019 02:06:28 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1220725https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1220725omb_number: 0938-0679

revision_date: Tue, 01 Dec 2009 12:00:00 -0500

special_instructions: N/A

title: CMN Positive Airway Pressure (PAP)Devices for Obstructive Sleep Apnea

]]>CMS 2540-96Mon, 04 Nov 2019 02:06:28 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019499https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019499omb_number: 0938-0463

revision_date: Mon, 01 May 2006 12:00:00 -0400

special_instructions: N/A

title: SNF AND SNF HEALTH CARE COMPLEX COST REPORT

]]>CMS 20017Mon, 04 Nov 2019 02:06:28 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms020383https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms020383omb_number: EXEMPT

revision_date: Sat, 01 Apr 2017 12:00:00 -0400

special_instructions: N/A

title: ADVISORY PANEL ON HOSPITAL OUTPATIENT PAYMENT

]]>CMS 10198Mon, 04 Nov 2019 02:06:28 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1198447https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1198447omb_number: 0938-1013

revision_date: Wed, 27 Dec 2017 12:00:00 -0500

special_instructions: N/A

title: Creditable Coverage Disclosure to CMS On-line Form and Instructions

]]>CMS 1490SMon, 04 Nov 2019 02:06:28 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms012949https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms012949omb_number: 0938-1197

revision_date: Tue, 01 Jun 2021 12:00:00 -0400

special_instructions: Effective April 1, 2019, only the revised 01-18 version will be accepted for the Form CMS-1490S. The provided link below includes the form and all the applicable instructions. Please read all instructions prior to submitting a claim to Medicare.(1) The Form CMS-1490S is fillable, can be completed online, printed then mailed. (2) Mail the completed form and itemized bills to the correct Medicare Administrative Contractor as indicated on pages 7 through 18 of the instructions.

title: PATIENT'S REQUEST FOR MEDICAL PAYMENT (English/Spanish)

]]>CMS 633Mon, 04 Nov 2019 02:06:28 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006200https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006200omb_number: EXMPT

revision_date: Tue, 01 Jan 2008 12:00:00 -0500

special_instructions: N/A

title: Invoice of Fees for FOIA Services

]]>CMS 846Mon, 04 Nov 2019 02:06:28 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006674https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006674omb_number: 0938-0679

revision_date: Wed, 01 Feb 2017 12:00:00 -0500

special_instructions: This form must be used starting January 1, 2007.

title: Certificate of Medical Necessity - Pneumatic Compression Devices DME 04.04B

]]>CMS 632FOIMon, 04 Nov 2019 02:06:28 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms048895https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms048895omb_number: EXEMPT

revision_date: Fri, 01 Mar 2013 12:00:00 -0500

special_instructions: N/A

title: FREEDOM OF INFORMATION ACT REQUEST

]]>CMS 10156Mon, 04 Nov 2019 02:06:28 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms058773https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms058773omb_number: 0938-0957

revision_date: Mon, 01 Aug 2005 12:00:00 -0400

special_instructions: N/A

title: Retiree Drug Subsidy

]]>CMS L564Mon, 04 Nov 2019 02:06:28 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms009718https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms009718omb_number: 0938-0787

revision_date: Sat, 30 Sep 2023 12:00:00 -0400

special_instructions: Use this form to show proof of group health plan coverage based on current employment for Medicare enrollment by completing Section A yourself and having your employer fill out Section B. Submit the completed and signed form along with your Request for Enrollment in Medicare Part B (Medical Insurance) (CMS-40B) by mail or fax to your local Social Security office, which you can locate at SSA.gov/locator. Contact Social Security at 1-800-772-1213 (TTY 1-800-325-0778) with questions.

title: Medicare Request for Employment Information

]]>CMS 10036Mon, 04 Nov 2019 02:06:28 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms056691https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms056691omb_number: 0938-0842

revision_date: Sun, 01 Jan 2006 12:00:00 -0500

special_instructions: N/A

title: Inpatient Rehabilitation Facility-Patient Assessment Instrument

]]>CMS R-0235L (64 KB)Mon, 04 Nov 2019 02:06:28 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms045945https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms045945omb_number: 0938-0734

revision_date: Thu, 11 Jun 2020 12:00:00 -0400

special_instructions: N/A

title: Data Use Agreement (DUA)- Limited Data Sets

]]>CMS 2744AMon, 04 Nov 2019 02:06:28 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms009579https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms009579omb_number: 0938-0447

revision_date: Mon, 01 Sep 2025 12:00:00 -0400

special_instructions: To obtain copies of these forms, please contact your End Stage Renal Disease (ESRD) Network (see link below)

title: ESRD FACILITY SURVEY (DIALYSIS UNIT ONLY)

]]>CMS 724Mon, 04 Nov 2019 02:06:27 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006601https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006601omb_number: 0938-0378

revision_date: Thu, 01 Sep 1994 12:00:00 -0400

special_instructions: N/A

title: Medicare/Medicaid Psychiatric Hospital Survey Data

]]>CMS 802Mon, 04 Nov 2019 02:06:27 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006620https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006620omb_number: EXEMPT

revision_date: Tue, 24 Oct 2023 12:00:00 -0400

special_instructions: N/A

title: Roster/Sample Matrix

]]>CMS 1696Mon, 04 Nov 2019 02:06:27 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms012207https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms012207omb_number: 0938-0950

revision_date: Wed, 09 Sep 2026 12:00:00 -0400

special_instructions: The Appointment of Representative Form CMS-1696 is currently awaiting OMB approval. Until an updated form is available, the current form (or any similar conforming written instrument) may be used.

title: APPOINTMENT OF REPRESENTATIVE

]]>CMS 2786RMon, 04 Nov 2019 02:06:27 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms009335https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms009335omb_number: Exempt

revision_date: Sun, 01 Jul 2018 12:00:00 -0400

special_instructions: N/A

title: Fire Safety Survey Report - Health Care 2012 Life Safety Code

]]>CMS 2786VMon, 04 Nov 2019 02:06:27 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008873https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008873omb_number: Exempt

revision_date: Sun, 01 Jul 2018 12:00:00 -0400

special_instructions: N/A

title: Fire Safety Survey Report - ICF-IID (Small Facilities) 2012 Life Safety Code

]]>CMS 2786WMon, 04 Nov 2019 02:06:27 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008881https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008881omb_number: Exempt

revision_date: Sun, 01 Jul 2018 12:00:00 -0400

special_instructions: N/A

title: Fire Safety Survey Report - ICF-IID (Large Facilities) 2012 Life Safety Code

]]>CMS 1561AMon, 04 Nov 2019 02:06:27 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019485https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019485omb_number: 0938-0832

revision_date: Mon, 01 Dec 2025 12:00:00 -0500

special_instructions: N/A

title: HEALTH INSURANCE BENEFIT AGREEMENT-RURAL HEALTH CLINIC

]]>CMS 1882Mon, 04 Nov 2019 02:06:27 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms012220https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms012220omb_number: 0938-0027

revision_date: Sun, 01 Feb 2009 12:00:00 -0500

special_instructions: N/A

title: PORTABLE XRAY SURVEY REPORT

]]>CMS 29Mon, 04 Nov 2019 02:06:27 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008849https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008849omb_number: 0938-0074

revision_date: Wed, 01 Jun 2022 12:00:00 -0400

special_instructions: N/A

title: VERIFICATION OF CLINIC DATA ? RURAL HEALTH CLINIC PROGRAM

]]>CMS 1728Mon, 04 Nov 2019 02:06:27 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019489https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019489omb_number: 0938-0022

revision_date: Fri, 01 Jun 2001 12:00:00 -0400

special_instructions: N/A

title: HOME HEALTH AGENCY COST REPORT

]]>CMS R-285Mon, 04 Nov 2019 02:06:27 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms060878https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms060878omb_number: 0938-0769

revision_date: Fri, 01 Nov 2024 12:00:00 -0400

special_instructions: Use this form to request a Medicare Part A (Hospital Insurance) premium reduction based on your employment by a state or local government. Submit your completed and signed form by mail, fax, or by visiting your local Social Security office in person. Find an office near you at SSA.gov/locator. Contact Social Security at 1-800-772-1213 (TTY 1-800-325-0778) with questions.

title: Medicare Request for Retirement Benefit Information

]]>CMS 3070IMon, 04 Nov 2019 02:06:27 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008821https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008821omb_number: 0938-0062

revision_date: Sun, 01 Oct 1995 12:00:00 -0400

special_instructions: N/A

title: INDIVIDUAL OBSERVATION WORKSHEET

]]>CMS 116Mon, 04 Nov 2019 02:06:27 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms012169https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms012169omb_number: 0938-0581

revision_date: Wed, 03 Mar 2027 12:00:00 -0500

special_instructions: N/A

title: CLINICAL LABORATORY IMPROVEMENT AMENDMENTS OF 1988 (CLIA) APPLICATION FOR CERTIFICATION

]]>CMS 1500Mon, 04 Nov 2019 02:06:27 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1188854https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1188854title: Health Insurance Claim Form

]]>CMS 588Mon, 04 Nov 2019 02:06:27 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006198https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006198omb_number: 0938-0626

revision_date: Thu, 02 Nov 2023 12:00:00 -0400

special_instructions: N/A

title: Electronic Funds Transfer (EFT) Authorization Agreement

]]>CMS 379Mon, 04 Nov 2019 02:06:27 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008774https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008774omb_number: 0938-0270

revision_date: Sun, 01 Jul 2007 12:00:00 -0400

special_instructions: N/A

title: FINANCIAL STATEMENT OF DEBTOR

]]>CMS 2786UMon, 04 Nov 2019 02:06:27 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms009395https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms009395omb_number: Exepmt

revision_date: Sun, 01 Jul 2018 12:00:00 -0400

special_instructions: N/A

title: Fire Safety Survey Report - ASC & ESRD 2012 Life Safety Code

]]>CMS 383Mon, 04 Nov 2019 02:06:26 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1199192https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1199192revision_date: Wed, 01 Dec 1982 12:00:00 -0500

special_instructions: N/A

title: HEALTH INSURANCE CASE SUMMARY

]]>CMS 726Mon, 04 Nov 2019 02:06:26 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006607https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006607omb_number: 0938-0378

revision_date: Thu, 01 Sep 1994 12:00:00 -0400

special_instructions: N/A

title: CMS Death Record Review Data Sheet

]]>CMS 1539Mon, 04 Nov 2019 02:06:26 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms011722https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms011722omb_number: EXEMPT

revision_date: Sun, 01 Jul 1984 12:00:00 -0400

special_instructions: N/A

title: MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL

]]>CMS 1984Mon, 04 Nov 2019 02:06:26 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019494https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019494omb_number: 0938-0758

revision_date: Tue, 01 Feb 2005 12:00:00 -0500

special_instructions: N/A

title: HOSPICE COST REPORT

]]>CMS 10106Mon, 04 Nov 2019 02:06:26 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1193148https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1193148omb_number: 0938-0930

revision_date: Mon, 22 May 2023 11:00:00 -0400

special_instructions: To fill out and submit the form online, go to the "Related Links" below and click "Medicare Online Forms"

title: 1-800-Medicare Authorization to Disclosure Personal Health Information

]]>CMS 18F5Mon, 04 Nov 2019 02:06:26 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms017337https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms017337omb_number: 0938-0251

revision_date: Tue, 01 Jul 2025 12:00:00 -0400

special_instructions: This application is for people age 65 and older (or turning 65 within 3 months) who want to apply for Medicare Part A hospital coverage. Submit your completed and signed form by mail, fax, or by visiting your local Social Security office in person. For questions or assistance, call Social Security at 1-800-772-1213 (TTY 1-800-325-0778) or visit SSA.gov/locator to find your local office.

title: Application for Medicare Part A (Hospital Insurance)

]]>CMS R-131Mon, 04 Nov 2019 02:06:26 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms012932https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms012932omb_number: 0938-0566

revision_date: Tue, 01 Mar 2011 12:00:00 -0500

special_instructions: N/A

title: ADVANCE BENEFICIARY NOTICE (ABN)

]]>CMS 417Mon, 04 Nov 2019 02:06:26 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms020294https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms020294omb_number: 0938-0313

revision_date: Fri, 13 Feb 2026 12:00:00 -0500

special_instructions: N/A

title: HOSPICE REQUEST FOR CERTIFICATION IN MEDICARE

]]>CMS 2802Mon, 04 Nov 2019 02:06:26 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms009406https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms009406omb_number: EXEMPT

revision_date: Tue, 01 Feb 2011 12:00:00 -0500

special_instructions: N/A

title: REQUEST FOR VALIDATION OF ACCREDITATION

]]>CMS 2802DMon, 04 Nov 2019 02:06:26 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms009514https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms009514omb_number: EXEMPT

revision_date: Tue, 01 Feb 2011 12:00:00 -0500

special_instructions: N/A

title: REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR AMBULATORY SURGICAL CENTER

]]>CMS 384Mon, 04 Nov 2019 02:06:26 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008803https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008803omb_number: EXEMPT

revision_date: Sun, 01 Mar 1992 12:00:00 -0500

special_instructions: N/A

title: QIO CASE SUMMARY

]]>CMS 287Mon, 04 Nov 2019 02:06:26 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019459https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019459omb_number: 0938-0202

revision_date: Wed, 01 Nov 1995 12:00:00 -0500

special_instructions: N/A

title: HOME OFFICE COST STATEMENT

]]>CMS 671Mon, 04 Nov 2019 02:06:26 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006581https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006581omb_number: EXEMPT

revision_date: Fri, 01 Sep 2023 12:00:00 -0400

special_instructions: N/A

title: LTC Facility Application for Medicare/Medicaid

]]>CMS 807Mon, 04 Nov 2019 02:06:26 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006633https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006633omb_number: EXEMPT

revision_date: Fri, 01 Mar 2024 12:00:00 -0500

special_instructions: N/A

title: Surveyor Notes Worksheet

]]>CMS 1557Mon, 04 Nov 2019 02:06:26 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms013075https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms013075omb_number: 0938-0544

revision_date: Mon, 01 Feb 2021 12:00:00 -0500

special_instructions: N/A

title: SURVEY REPORT FORM - CLIA

]]>CMS 10221Mon, 04 Nov 2019 02:06:26 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1207001https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1207001omb_number: 0938-1029

revision_date: Mon, 01 Jan 2024 12:00:00 -0500

special_instructions: N/A

title: Independent Diagnostic Testing Facilities-Site Investigation

]]>CMS 4040Mon, 04 Nov 2019 02:06:26 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms007776https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms007776omb_number: 0938-0245

revision_date: Tue, 01 Jul 2025 12:00:00 -0400

special_instructions: Use this form to enroll in Medicare Part B if you’re NOT entitled to Social Security/Railroad Retirement Board benefits. Submit your completed and signed form by mail, fax, or by visiting your local Social Security office in person. Find an office near you at SSA.gov/locator. Contact Social Security at 1-800-772-1213 (TTY 1-800-325-0778) with questions.

title: Request for Enrollment in Medicare Part B (Medical Insurance)

]]>CMS 460Mon, 04 Nov 2019 02:06:26 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms007566https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms007566omb_number: 0938-0373

revision_date: Sun, 31 Dec 2028 12:00:00 -0500

special_instructions: N/A

title: MEDICARE PARTICIPATING PHYSICIAN OR SUPPLIER AGREEMENT

]]>CMS 2786XMon, 04 Nov 2019 02:06:26 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms048764https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms048764omb_number: Exempt

revision_date: Sun, 01 Jul 2018 12:00:00 -0400

special_instructions: N/A

title: Fire Safety Survey Report - ICF-IID (Apartment House) 2012 Life Safety Code

]]>CMS 2567BMon, 04 Nov 2019 02:06:25 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms009564https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms009564omb_number: EXEMPT

revision_date: Tue, 01 Sep 1992 12:00:00 -0400

special_instructions: N/A

title: POST-CERTIFICATION REVISIT REPORT

]]>CMS 222Mon, 04 Nov 2019 02:06:25 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019164https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019164omb_number: 0938-0107

revision_date: Sat, 01 Jan 2005 12:00:00 -0500

special_instructions: N/A

title: INDEPENDENT RURAL HEALTH CLINIC WORKSHEET

]]>CMS 2878Mon, 04 Nov 2019 02:06:25 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms009585https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms009585omb_number: EXEMPT

revision_date: Tue, 01 Apr 1986 12:00:00 -0500

special_instructions: N/A

title: ACCREDITED HOSPITAL ALLEGATIONS REPORT

]]>CMS 801Mon, 04 Nov 2019 02:06:25 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006618https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006618omb_number: EXEMPT

revision_date: Sat, 01 Jul 1995 12:00:00 -0400

special_instructions: N/A

title: Offsite Survey Prep Worksheet

]]>CMS 672Mon, 04 Nov 2019 02:06:25 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006583https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006583omb_number: EXEMPT

revision_date: Tue, 01 May 2012 12:00:00 -0400

special_instructions: Effective 10/22/23, the CMS-672 form is no longer in use and has been replaced with a revised CMS-671 form.

title: Resident Census and Conditions of Residents

]]>CMS 10114Mon, 04 Nov 2019 02:06:25 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms013118https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms013118omb_number: 0938-0931

revision_date: Sat, 01 Feb 2025 12:00:00 -0500

special_instructions: N/A

title: NATIONAL PROVIDER IDENTIFIER (NPI) APPLICATION/UPDATE FORM

]]>CMS 838Mon, 04 Nov 2019 02:06:25 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006634https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006634omb_number: 0938-0600

revision_date: Wed, 01 Oct 2003 12:00:00 -0400

special_instructions: N/A

title: Medicare Credit Balance Reporting Requirements

]]>CMS 1541BMon, 04 Nov 2019 02:06:25 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms013070https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms013070omb_number: EXEMPT

revision_date: Mon, 01 Sep 2014 12:00:00 -0400

special_instructions: N/A

title: RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN EMERGENCY CASES INVESTIGATION REPORT

]]>CMS 43Mon, 04 Nov 2019 02:06:25 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms017342https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms017342omb_number: 0938-0080

revision_date: Sun, 01 Dec 2024 12:00:00 -0500

special_instructions: Complete this form to apply for Medicare if you End-Stage Renal Disease (ESRD), regardless of your age. Submit the completed and signed CMS-43 and CMS-2728 ESRD Medical Evidence Report completed by your healthcare provider by mail, fax, or by visiting your local Social Security Office in person. Find an office near you at SSA.gov/locator. Contact Social Security at 1-800-772-1213 (TTY 1-800-325-0778) with questions.

title: Application for Part A (Hospital Insurance) and Part B (Medical Insurance) for People with End-Stage Renal Disease

]]>CMS 10252Mon, 04 Nov 2019 02:06:25 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1214081https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1214081omb_number: 0938-0734

revision_date: Wed, 27 Apr 2022 12:00:00 -0400

special_instructions: N/A

title: DATA USE AGREEMENT (DUA) CERTFICATE OF DISPOSITION (COD) FOR DATA ACQUIRED FROM THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)

]]>CMS 725Mon, 04 Nov 2019 02:06:25 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006605https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006605omb_number: 0938-0378

revision_date: Thu, 01 Sep 1994 12:00:00 -0400

special_instructions: N/A

title: Surveyor Worksheet for Psychiatric Hospital Review:Two Special Conditions

]]>CMS 727Mon, 04 Nov 2019 02:06:25 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006611https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006611omb_number: 0938-0378

revision_date: Thu, 01 Sep 1994 12:00:00 -0400

special_instructions: N/A

title: CMS Nursing Complement Data

]]>CMS 1771Mon, 04 Nov 2019 02:06:25 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms013088https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms013088omb_number: 0938-0023

revision_date: Thu, 01 Sep 1977 12:00:00 -0400

special_instructions: N/A

title: ATTENDING PHYSICIANS STATEMENT AND DOCUMENTATION FOR MEDICARE EMERGENCY

]]>CMS 484Mon, 04 Nov 2019 02:06:25 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms007682https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms007682omb_number: 0938-0534

revision_date: Wed, 01 Feb 2017 12:00:00 -0500

special_instructions: This form must be used starting January 1, 2007.

title: CERTIFICATE OF MEDICAL NECESSITY - Oxygen DME 484.5

]]>CMS 359Mon, 04 Nov 2019 02:06:25 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008714https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008714omb_number: 0938-0267

revision_date: Thu, 01 Apr 2021 12:00:00 -0400

special_instructions: N/A

title: CORF REPORT FOR CERTIFICATION TO PARTICIPATE IN MEDICARE

]]>CMS 1563Mon, 04 Nov 2019 02:06:25 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms012447https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms012447omb_number: EXEMPT

revision_date: Sat, 01 Nov 1997 12:00:00 -0500

special_instructions: N/A

title: Monthly Intermediary Report on Medicare Secondary Payer Savings

]]>CMS 2802CMon, 04 Nov 2019 02:06:25 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms009506https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms009506omb_number: EXEMPT

revision_date: Sun, 31 Mar 2019 12:00:00 -0400

special_instructions: N/A

title: REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR HOME HEALTH AGENCY

]]>CMS 1880Mon, 04 Nov 2019 02:06:25 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms013094https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms013094omb_number: 0938-0027

revision_date: Thu, 31 May 2018 12:00:00 -0400

special_instructions: N/A

title: REQUEST FOR CERTIFICATION AS SUPPLIER OF PORTABLE XRAY SERVICES

]]>CMS 2552-96Mon, 04 Nov 2019 02:06:25 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019505https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019505omb_number: 0938-0050

revision_date: Sat, 01 May 2004 12:00:00 -0400

special_instructions: N/A

title: COST REPORT FOR ELECTRONIC FILING OF HOSPITALS

]]>CMS 40BMon, 04 Nov 2019 02:06:25 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms017339https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms017339omb_number: 0938-1230

revision_date: Tue, 01 Jul 2025 12:00:00 -0400

special_instructions: Use this form if you already have Medicare Part A and want to sign up for Part B (Medical Insurance). If you don't have Part A, don't complete this application —instead, contact Social Security to apply for Medicare for the first time. Submit your completed and signed form by mail, fax, or by visiting your local Social Security office in person. Find an office near you at SSA.gov/locator. Contact Social Security at 1-800-772-1213 (TTY 1-800-325-0778) with questions.

title: Request for Enrollment in Medicare Part B (Medical Insurance)

]]>CMS 576Mon, 04 Nov 2019 02:06:25 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006171https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006171omb_number: 0938-0512

revision_date: Fri, 01 Jan 1993 12:00:00 -0500

special_instructions: N/A

title: Organ Procurement Request for Designation as an OPO

]]>CMS R-193Mon, 04 Nov 2019 02:06:25 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms012941https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms012941omb_number: 0938-0692

revision_date: Thu, 01 Jul 2010 12:00:00 -0400

special_instructions: N/A

title: IMPORTANT MESSAGE FROM MEDICARE (IM)

]]>CMS 179Mon, 04 Nov 2019 02:06:25 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms012182https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms012182omb_number: 0938-0193

revision_date: Mon, 01 Jan 2024 13:00:00 -0500

special_instructions: N/A

title: TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

]]>CMS 10055Mon, 04 Nov 2019 02:06:24 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019508https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019508special_instructions: N/A

title: SKILLED NURSING FACILITY ADVANCED BENEFICIARY NOTICE

]]>CMS 20033Mon, 04 Nov 2019 02:06:24 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms020393https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms020393omb_number: EXEMPT

revision_date: Mon, 01 Jul 0019 12:00:00 -0456

special_instructions: N/A

title: MEDICARE RECONSIDERATION REQUEST FORM

]]>CMS 500Mon, 04 Nov 2019 02:06:24 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms017348https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms017348revision_date: Wed, 01 May 2024 12:00:00 -0400

special_instructions: You must either visit or contact the Social Security Administration to obtain this form. 1-800-772-1213

title: MEDICARE PREMIUM BILL

]]>CMS 36PMon, 04 Nov 2019 02:06:24 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008696https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms008696omb_number: EXEMPT

revision_date: Mon, 01 Jul 2002 12:00:00 -0400

special_instructions: N/A

title: CONSENT FOR HOME VISIT FOR PACE SERVICES EVALUATION

]]>CMS 462LMon, 04 Nov 2019 02:06:24 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms007663https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms007663omb_number: EXEMPT

revision_date: Sat, 01 Jul 1995 12:00:00 -0400

special_instructions: N/A

title: ADVERSE ACTI0N EXTRACT FOR SNFs AND NFs

]]>CMS 1666Mon, 04 Nov 2019 02:06:24 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms013081https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms013081omb_number: EXEMPT

revision_date: Tue, 01 Apr 1980 12:00:00 -0500

special_instructions: N/A

title: REGIONAL OFFICE REQUEST FOR ADDITIONAL INFORMATION

]]>CMS 265Mon, 04 Nov 2019 02:06:24 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019166https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019166omb_number: 0938-0236

revision_date: Tue, 01 Mar 2005 12:00:00 -0500

special_instructions: N/A

title: INDEPENDENT RENAL DIALYSIS FACILITY COST REPORT

]]>CMS 729Mon, 04 Nov 2019 02:06:24 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006615https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006615omb_number: 0938-0378

revision_date: Thu, 01 Sep 1994 12:00:00 -0400

special_instructions: N/A

title: Data Collection Medical Staff Coverage

]]>CMS 1561Mon, 04 Nov 2019 02:06:24 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms012196https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms012196omb_number: 0938-0832

revision_date: Mon, 01 Dec 2025 12:00:00 -0500

special_instructions: N/A

title: HEALTH INSURANCE BENEFIT AGREEMENT

]]>CMS 216Mon, 04 Nov 2019 02:06:24 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019162https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019162omb_number: 0938-0102

revision_date: Tue, 01 Nov 2005 12:00:00 -0500

special_instructions: N/A

title: ORGAN PROCUREMENT ORGANIZATION-HISTO-COMPATIBILITY LAB STATEMENT OF REIMBURSABLE COSTS

]]>CMS 2802BMon, 04 Nov 2019 02:06:24 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms009494https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms009494omb_number: EXEMPT

revision_date: Tue, 01 Feb 2011 12:00:00 -0500

special_instructions: N/A

title: REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR HOSPICE

]]>CMS 576AMon, 04 Nov 2019 02:06:24 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006189https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms006189omb_number: 0938-0512

revision_date: Fri, 30 Jun 2006 12:00:00 -0400

special_instructions: N/A

title: Health Insurance Benefits Agreement with Organ Procurement Organization

]]>CMS 2007Mon, 04 Nov 2019 02:06:24 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms009554https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms009554omb_number: EXEMPT

revision_date: Mon, 01 Mar 1982 12:00:00 -0500

special_instructions: N/A

title: PROVIDER TIE IN NOTICE

]]>CMS 20041Mon, 04 Nov 2019 02:06:23 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms056041https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms056041omb_number: EXEMPT

revision_date: Thu, 01 Dec 0005 12:00:00 -0456

special_instructions: N/A

title: Speech Invitation Request Background Information

]]>CMS 1960Mon, 04 Nov 2019 02:06:23 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms017355https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms017355omb_number: EXEMPT

revision_date: Thu, 01 May 1969 12:00:00 -0400

special_instructions: You must either visit or contact the Social Security Administration to obtain this form. 1-800-772-1213

title: REQUEST FOR EVIDENCE OF MEDICAL NECESSITY

]]>CMS 2384Mon, 04 Nov 2019 02:06:23 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms017357https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms017357title: THIRD PARTY PREMIUM BILLING REQUEST, MEDICARE

]]>CMS 416Mon, 04 Nov 2019 02:06:23 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1184680https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms1184680omb_number: 0938-0354

revision_date: Tue, 01 Jun 1999 12:00:00 -0400

special_instructions: N/A

title: Early ad Periodic Screening Diagnostic and Treatment Participation Report

]]>CMS 821Mon, 04 Nov 2019 02:06:21 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019471https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms019471omb_number: EXEMPT

revision_date: Sat, 01 Jan 2005 12:00:00 -0500

special_instructions: N/A

title: PERITONEAL DIALYSIS CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2005

]]>CMS 20040Mon, 04 Nov 2019 02:06:21 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms056040https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms056040omb_number: EXEMPT

revision_date: Thu, 01 Dec 0005 12:00:00 -0456

special_instructions: N/A

title: Regional Office Meeting/Speaker Request Form

]]>CMS 1592Mon, 04 Nov 2019 02:06:21 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms017352https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms017352omb_number: EXEMPT

revision_date: Tue, 01 Jul 1986 12:00:00 -0400

special_instructions: You must either visit or contact the Social Security Administration to obtain this form. 1-800-772-1213

title: SMI PREMIUM ACCTG FORM

]]>CMS 20027Mon, 04 Nov 2019 02:06:21 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms020385https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms020385omb_number: EXEMPT

revision_date: Mon, 01 Jul 0019 12:00:00 -0456

special_instructions: N/A

title: MEDICARE REDETERMINATION REQUEST FORM

]]>CMS 20031Mon, 04 Nov 2019 02:06:21 -0500https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms020388https://www.cms.gov//medicare/cms-forms/cms-forms/cms-forms-items/cms020388form_number: CMS 20031

manual_section: IOM Pub 100.-04, Chapter 29, section 270.2.3

omb_number: EXEMPT

revision_date: Thu, 01 Mar 2018 12:00:00 -0500

special_instructions: N/A

title: TRANSFER (ASSIGNMENT) OF APPEAL RIGHTS

]]>