CMS Forms List
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
|
|
Inpatient Rehabilitation Facility-Patient Assessment Instrument
|
2006-01-01
|
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SKILLED NURSING FACILITY ADVANCED BENEFICIARY NOTICE
|
||
Medicare Waiver Demonstration Application
|
2013-12-31
|
|
Detailed Explanation of Non-Coverage
|
2006-12-01
|
|
NOTICE OF MEDICARE NON-COVERAGE
|
2006-12-01
|
|
1-800-Medicare Authorization to Disclosure Personal Health Information
|
2023-05-22
|
|
NATIONAL PROVIDER IDENTIFIER (NPI) APPLICATION/UPDATE FORM
|
2021-08-01
|
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EXPEDITED REVIEW NOTICE-NOTICE OF MEDICARE PROVIDER NON-COVERAGE
|
2008-02-29
|
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EXPEDITED REVIEW NOTICE-DETAILED EXPLANATION OF NON-COVERAGE
|
2008-02-29
|
|
DME Information Form - External Infusion Pumps DME 09.03
|
2017-02-01
|
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DME Information Form - Enteral and Parenteral Nutrition DME 10.03
|
2017-02-01
|
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Notice of Denial of Medicare Prescription Drug Coverage English/Spanish
|
2019-01-01
|
|
Retiree Drug Subsidy
|
2005-08-01
|
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Centers for Medicare and Medicaid Services EDI Registration Form; and EDI Enrollment Form
|
2024-08-26
|
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Electronic File Interchange Organization (EFIO) Certification Statement
|
2022-03-01
|
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Creditable Coverage Disclosure to CMS On-line Form and Instructions
|
2017-12-27
|
|
Independent Diagnostic Testing Facilities-Site Investigation
|
2024-01-01
|
|
DATA USE AGREEMENT (DUA) CERTFICATE OF DISPOSITION (COD) FOR DATA ACQUIRED FROM THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
|
2022-04-27
|
|
CMN Positive Airway Pressure (PAP)Devices for Obstructive Sleep Apnea
|
2009-12-01
|
|
Medicare Quality of Care Complaint Form
|
2015-11-01
|
|
Application for Enrollment in Part B Immunosuppressive Drug Coverage
|
2023-02-01
|
|
ADA Dental Claim Form
|
2024-08-01
|
|
CLINICAL LABORATORY IMPROVEMENT AMENDMENTS OF 1988 (CLIA) APPLICATION FOR CERTIFICATION
|
2020-04-01
|
|
UB-04 Uniform Bill
|
2007-03-01
|
|
PATIENT'S REQUEST FOR MEDICAL PAYMENT (English/Spanish)
|
2021-06-01
|
|
Health Insurance Claim Form
|
2012-02-01
|
|
HHA Functional Assessment Instrumental
|
2013-05-01
|
|
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL
|
1984-07-01
|
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RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN EMERGENCY CASES INVESTIGATION REPORT
|
2014-09-01
|
|
SURVEY REPORT FORM - CLIA
|
2021-02-01
|
|
HEALTH INSURANCE BENEFIT AGREEMENT
|
2024-01-19
|
|
HEALTH INSURANCE BENEFIT AGREEMENT-RURAL HEALTH CLINIC
|
2024-01-19
|
|
Monthly Intermediary Report on Medicare Secondary Payer Savings
|
1997-11-01
|
|
MONTHLY CARRIER REPORT ON MEDICARE SECONDARY PAYER SAVINGS
|
1997-11-01
|
|
HHA SURVEY REPORT
|
2022-07-01
|
|
SMI PREMIUM ACCTG FORM
|
1986-07-01
|
|
REGIONAL OFFICE REQUEST FOR ADDITIONAL INFORMATION
|
1980-04-01
|
|
APPOINTMENT OF REPRESENTATIVE
|
2024-09-01
|
|
HOME HEALTH AGENCY COST REPORT
|
2001-06-01
|
|
Request for Termination of Premium Hospital Insurance of Supplementary Medical Insurance
|
2022-01-31
|
|
ATTENDING PHYSICIANS STATEMENT AND DOCUMENTATION FOR MEDICARE EMERGENCY
|
1977-09-01
|
|
TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL
|
2024-01-01
|
|
APPLICATION FOR PART A (HOSPITAL INSURANCE)
|
2023-06-30
|
|
Request for Certification in the Medicare and/or Medicaid Program to Provide Outpatient Physical Therapy and/or Speech Pathology Services
|
2006-12-11
|
|
REQUEST FOR CERTIFICATION AS SUPPLIER OF PORTABLE XRAY SERVICES
|
2018-05-31
|
|
PORTABLE XRAY SURVEY REPORT
|
2009-02-01
|
|
SSO REPORT OF STATE BUY IN PROBLEM
|
2018-04-01
|
|
REQUEST FOR EVIDENCE OF MEDICAL NECESSITY
|
1969-05-01
|
|
CARRIER OR INTERMEDIARY REQUEST FOR SSO ASSISTANCE
|
1978-03-01
|
|
HOSPICE COST REPORT
|
2005-02-01
|
|
ADVISORY PANEL ON HOSPITAL OUTPATIENT PAYMENT
|
2017-04-01
|
|
MEDICARE REDETERMINATION REQUEST FORM
|
0019-07-01
|
|
TRANSFER (ASSIGNMENT) OF APPEAL RIGHTS
|
2018-03-01
|
|
MEDICARE RECONSIDERATION REQUEST FORM
|
0019-07-01
|
|
APPLICATION FOR ACCESS TO CMS COMPUTER SYSTEMS
|
2010-06-01
|
|
Regional Office Meeting/Speaker Request Form
|
0005-12-01
|
|
Speech Invitation Request Background Information
|
0005-12-01
|
|
Medicare Adminstration Observation
|
2013-02-01
|
|
PROVIDER TIE IN NOTICE
|
1982-03-01
|
|
Medicare Enrollment Application - Medicare Diabetes Prevention Program (MDPP) Suppliers
|
2018-01-01
|
|
Medicare Easy Pay Premium Statement
|
2024-05-01
|
|
OUTPATIENT REHAB PROVIDER COST REPORT
|
2004-12-01
|
|
LABORATORY PERSONNEL REPORT (CLIA)
|
2021-01-01
|
|
ORGAN PROCUREMENT ORGANIZATION-HISTO-COMPATIBILITY LAB STATEMENT OF REIMBURSABLE COSTS
|
2005-11-01
|
|
HI/SMI ENTITLEMENT PROBLEM REFERRAL
|
2006-09-01
|
|
INDEPENDENT RURAL HEALTH CLINIC WORKSHEET
|
2005-01-01
|
|
THIRD PARTY PREMIUM BILLING REQUEST, MEDICARE
|
2018-03-01
|
|
SNF AND SNF HEALTH CARE COMPLEX COST REPORT
|
2006-05-01
|
|
COST REPORT FOR ELECTRONIC FILING OF HOSPITALS
|
2004-05-01
|
|
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
|
2022-03-18
|
|
POST-CERTIFICATION REVISIT REPORT
|
1992-09-01
|
|
INDEPENDENT RENAL DIALYSIS FACILITY COST REPORT
|
2005-03-01
|
|
REQ FOR CANCELLATION OF SMI
|
1978-03-01
|
|
ESRD MEDICAL EVIDENCE REPORT MEDICARE ENTITLEMENT AND/OR PATIENT REGISTRATION
|
2024-06-01
|
|
ESRD FACILITY SURVEY (DIALYSIS UNIT ONLY)
|
2020-07-01
|
|
END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM ESRD FACILITY SURVEY (TRANSPLANT CENTERS ONLY)
|
2020-07-01
|
|
ESRD DEATH NOTIFICATION
|
2024-05-01
|
|
Worksheet for Determining Evacuation Capability - ICF-IID (Existing Facilities Only) 2012 Life Safety Code
|
2018-07-01
|
|
Fire Safety Survey Report - Health Care 2012 Life Safety Code
|
2018-07-01
|
|
Fire Safety Evaluation System - Health Care 2012 Life Safety Code
|
2022-10-01
|
|
Fire Safety Survey Report - ASC & ESRD 2012 Life Safety Code
|
2018-07-01
|
|
Fire Safety Survey Report - ICF-IID (Small Facilities) 2012 Life Safety Code
|
2018-07-01
|
|
Fire Safety Survey Report - ICF-IID (Large Facilities) 2012 Life Safety Code
|
2018-07-01
|
|
Fire Safety Survey Report - ICF-IID (Apartment House) 2012 Life Safety Code
|
2018-07-01
|
|
Fire Safety Evaluation System - ICF-IID (Small Facilities) 2012 Life Safety Code
|
2018-07-01
|
|
REQUEST FOR VALIDATION OF ACCREDITATION
|
2011-02-01
|
|
REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR HOSPICE
|
2011-02-01
|
|
REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR HOME HEALTH AGENCY
|
2019-03-31
|
|
REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR AMBULATORY SURGICAL CENTER
|
2011-02-01
|
|
REQUEST FOR VALIDATION OF ACCREDITATION FOR CRITICAL ACCESS HOSPITAL SURVEY
|
2011-02-01
|
|
Authorization for State Agency Psychiatric Hospital Validation Survey
|
2011-11-01
|
|
HOME OFFICE COST STATEMENT
|
1995-11-01
|
|
ACCREDITED HOSPITAL ALLEGATIONS REPORT
|
1986-04-01
|
|
VERIFICATION OF CLINIC DATA ? RURAL HEALTH CLINIC PROGRAM
|
2022-06-01
|
|
ICF/IID Survey Report
|
2013-03-01
|
|
ICF/IID Deficiencies Report
|
2013-03-01
|
|
INDIVIDUAL OBSERVATION WORKSHEET
|
1995-10-01
|
|
PROVIDER COST REPORT REIMBURSEMENT QUESTIONNAIRE
|
2006-04-30
|
|
CORF REPORT FOR CERTIFICATION TO PARTICIPATE IN MEDICARE
|
2021-04-01
|
|
CONSENT FOR HOME VISIT (English/Spanish)
|
1990-12-01
|
|
COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY SURVEY REPORT
|
2021-04-01
|
|
CONSENT FOR HOME VISIT FOR PACE SERVICES EVALUATION
|
2002-07-01
|
|
HEALTH INSURANCE BENEFITS AGREEMENT-AMBULATORY SURGICAL CENTER
|
2002-04-01
|
|
AMBULATORY SURGICAL CENTER REQUEST FOR CERTIFICATION IN MEDICARE
|
0021-02-28
|
|
FINANCIAL STATEMENT OF DEBTOR
|
2007-07-01
|
|
MODEL LETTER REQUESTING IDENTIFICATION OF EXTENSION LOCATIONS
|
2024-08-01
|
|
HEALTH INSURANCE CASE SUMMARY
|
1982-12-01
|
|
QIO CASE SUMMARY
|
1992-03-01
|
|
REQUEST FOR ENROLLMENT IN SUPPLEMENTARY MEDICAL INSURANCE (English / Spanish)
|
2023-09-30
|
|
Application for Enrollment in Medicare - Part B (Medical Insurance)
|
2024-01-10
|
|
Early ad Periodic Screening Diagnostic and Treatment Participation Report
|
1999-06-01
|
|
HOSPICE REQUEST FOR CERTIFICATION IN MEDICARE
|
2021-11-30
|
|
APPLICATION FOR HOSPITAL INSURANCE BENEFITS FOR INDIVIDUALS WITH END STAGE RENAL DISEASE
|
2023-02-28
|
|
PSYCHIATRIC UNIT CRITERIA WORKSHEET
|
2026-09-30
|
|
REHAB UNIT CRITERIA WORKSHEET
|
2026-09-30
|
|
REHAB HOSPITAL CRITERIA WORKSHEET
|
2026-09-30
|
|
MEDICARE PARTICIPATING PHYSICIAN OR SUPPLIER AGREEMENT
|
2022-11-01
|
|
ADVERSE ACTI0N EXTRACT FOR SNFs AND NFs
|
1995-07-01
|
|
CERTIFICATE OF MEDICAL NECESSITY - Oxygen DME 484.5
|
2017-02-01
|
|
MEDICARE PREMIUM BILL
|
2024-05-01
|
|
Organ Procurement Request for Designation as an OPO
|
1993-01-01
|
|
Health Insurance Benefits Agreement with Organ Procurement Organization
|
2006-06-30
|
|
Electronic Funds Transfer (EFT) Authorization Agreement
|
2023-11-02
|
|
FREEDOM OF INFORMATION ACT REQUEST
|
2013-03-01
|
|
Invoice of Fees for FOIA Services
|
2008-01-01
|
|
Hospice Survey AND Deficiencies Report
|
2008-06-01
|
|
LTC Facility Application for Medicare/Medicaid
|
2023-09-01
|
|
Resident Census and Conditions of Residents
|
2012-05-01
|
|
Medicare/Medicaid Psychiatric Hospital Survey Data
|
1994-09-01
|
|
Surveyor Worksheet for Psychiatric Hospital Review:Two Special Conditions
|
1994-09-01
|
|
CMS Death Record Review Data Sheet
|
1994-09-01
|
|
CMS Nursing Complement Data
|
1994-09-01
|
|
CMS Staff Data
|
1994-09-01
|
|
Data Collection Medical Staff Coverage
|
1994-09-01
|
|
Offsite Survey Prep Worksheet
|
1995-07-01
|
|
Roster/Sample Matrix
|
2023-10-24
|
|
Surveyor Notes Worksheet
|
2024-03-01
|
|
IN-CENTER HEMODIALYSIS (HD) CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2005
|
2005-01-01
|
|
PERITONEAL DIALYSIS CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2005
|
2005-01-01
|
|
Medicare Credit Balance Reporting Requirements
|
2003-10-01
|
|
Certificate of Medical Necessity - Pneumatic Compression Devices DME 04.04B
|
2017-02-01
|
|
Certificate of Medical Necessity - Osteogenesis Stimulators - DME 04.04C
|
2017-02-01
|
|
Certificate of Medical Necessity - Transcutaneous Electrical Nerve Stimulator (TENS) - DME 06.03B
|
2017-02-01
|
|
Certificate of Medical Necessity - Seat Lift Mechanisms - DME 07.03A
|
2017-02-01
|
|
Certificate of Medical Necessity - DME 11.02
|
2017-02-02
|
|
Medicare Enrollment Application - Institutional Providers
|
2024-09-01
|
|
Medicare Enrollment Application - Clinics/Group Practices and Certain Other Suppliers
|
2021-03-01
|
|
Medicare Enrollment Application - Physicians and Non-Physician Practitioners
|
2023-05-01
|
|
Medicare Enrollment Application - Registration For Eligible Ordering and Referring Physicians and Non-Physician Practitioners
|
2023-09-01
|
|
Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers
|
2023-12-01
|
|
REQUEST FOR EMPLOYMENT INFORMATION
|
2023-09-30
|
|
Addendum to Data Use Agreement (DUA)
|
2020-06-11
|
|
Data Use Agreement (DUA)- Limited Data Sets
|
2020-06-11
|
|
Medicaid Agency Data Use Agreement
|
2007-07-01
|
|
Addendum to the Medicaid State Agency Data Use Agreement
|
2006-03-01
|
|
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
|
|
ADVANCE BENEFICIARY NOTICE (ABN)
|
2011-03-01
|
|
IMPORTANT MESSAGE FROM MEDICARE (IM)
|
2010-07-01
|
|
Request for Retirement Benefit Information
|
2023-02-28
|
|
HOME HEALTH ADVANCE BENEFICIARY NOTICE
|
2009-08-01
|
|
Medication Therapy Management Program Standardize Format
|
2012-01-20
|
|
Report of a Hospital Death Associated with Restraint or Seclusion
|
2018-07-19
|
|
Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances)
|
2022-04-01
|
|
DSH Data Use Agreement for Cost Reporting Periods Prior to those that include December 8, 2004
|
2009-12-01
|
|
DSH Data Use Agreement for Cost Reporting Periods that Include December 8, 2004 and therafter
|
2009-12-01
|
Page Last Modified:
09/10/2024 06:06 PM