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Department of Health and Human Services

The forms listed below are the forms from the Center for Medicare and Medicaid Services which comes under the department of Health and Human Services.

FormTitle
CMS 10003NDMCNOTICE OF DENIAL OF MEDICAL COVERAGE
CMS 10003-NDPNOTICE OF DENIAL OF PAYMENT
CMS 10036Inpatient Rehabilitation Facility-Patient Assessment Instrument
CMS 10055SKILLED NURSING FACILITY ADVANCED BENEFICIARY NOTICE
CMS 10069Medicare Waiver Demonstration Application
CMS 10095DENCDetailed Explanation of Non-Ceverage
CMS 10095NOMNCNOTICE OF MEDICARE NON-COVERAGE
CMS 101061-800-Medicare Authorization to Disclosure Personal Health Information
CMS 10114NATIONAL PROVIDER IDENTIFIER (NPI) APPLICATION/UPDATE FORM
CMS 10115SECTION 1011 PROVIDER ENROLLMENT APPLICATION
CMS 10123EXPEDITED REVIEW NOTICE-NOTICE OF MEDICARE PROVIDER NON-COVERAGE
CMS 10124EXPEDITED REVIEW NOTICE-DETAILED EXPLANATION OF NON-COVERAGE
CMS 10125DME Information Form – External Infusion Pumps DME 09.03
CMS 10126DME Information Form – Enteral and Parenteral Nutrition DME 10.03
CMS 10130ASection 1011 Provider Payment Determination
CMS 10130BRequest for Section 1011 Hospital On-Call Payments to Physicians
CMS 10146Notice of Denial of Medicare Prescription Drug Coverage English/Spanish
CMS 10156Retiree Drug Subsidy
CMS 10164Centers for Medicare and Medicaid Services EDI Registration Form; and EDI Enrollment Form
CMS 10165Medicare Care Management Performance Demonstration Application to Participate
CMS 10167Competitive Acquisition Program (CAP) for Medicare Part B Drugs – CAP Physician Election Agreement
CMS 10175Electronic File Interchange Organization (EFIO) Certification Statement
CMS 10198Creditable Coverage Disclosure to CMS On-line Form and Instructions
CMS 10221Independent Diagnostic Testing Facilities-Site Investigation
CMS 10252Instructions for Completing the Certificate of Data Destruction for Data Acquired from the Centers for Medicare & Medicaid Services
CMS 116CLINICAL LABORATORY IMPROVEMENT AMENDMENTS OF 1988 (CLIA) APPLICATION FOR CERTIFICATION
CMS 1450UB-04 Uniform Bill
CMS 1490SPATIENT’S REQUEST FOR MEDICAL PAYMENT (English/Spanish)
CMS 1500Health Insurance Claim Form
CMS 1515AHHA Functional Assessment Instrumental: Module A
CMS 1515BHOME HEALTH FUNCTIONAL ASSESSMENT INSTRUMENT: MODULE B
CMS 1515CHOME HEALTH FUNCTIONAL ASSESSMENT MODULE C: HOME VISIT
CMS 1515DHOME HEALTH FUNCTIONAL ASSESSMENT PATIENT CARE: MODULE D
CMS 1515EHOME HEALTH FUNCTION AND CARE SUMMARY: MODULE E
CMS 1515FCALENDAR WORKSHEET – PRESCRIBED VISITS
CMS 1537CMedicare/Medicaid Hospital Swing-Bed Survey Report
CMS 1539MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL
CMS 1541ARESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN EMERGENCY CASES
CMS 1541BRESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN EMERGENCY CASES INVESTIGATION REPORT
CMS 1557SURVEY REPORT FORM – CLIA
CMS 1561HEALTH INSURANCE BENEFIT AGREEMENT
CMS 1561AHEALTH INSURANCE BENEFIT AGREEMENT-RURAL HEALTH CLINIC
CMS 1563Monthly Intermediary Report on Medicare Secondary Payer Savings
CMS 1564MONTHLY CARRIER REPORT ON MEDICARE SECONDARY PAYER SAVINGS
CMS 1572AHHA SURVEY AND DEFICIENCIES REPORT
CMS 1592SMI PREMIUM ACCTG FORM
CMS 1666REGIONAL OFFICE REQUEST FOR ADDITIONAL INFORMATION
CMS 1696APPOINTMENT OF REPRESENTATIVE
CMS 1728HOME HEALTH AGENCY COST REPORT
CMS 1763REQ FOR TERMINATION OF PREMIUM HI/SMI
CMS 1771ATTENDING PHYSICIANS STATEMENT AND DOCUMENTATION FOR MEDICARE EMERGENCY
CMS 179TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL
CMS 1856Request for Certification in the Medicare and/or Medicaid Program to Provide Outpatient Physical Therapy and/or Speech Pathology Services
CMS 1880REQUEST FOR CERTIFICATION AS SUPPLIER OF PORTABLE XRAY SERVICES
CMS 1882PORTABLE XRAY SURVEY REPORT
CMS 1893OUTPATIENT PHYSICAL THERAPY – SPEECH PATHOLOGY SURVEY REPORT
CMS 18FAPPLICATION FOR HOSPITAL INSURANCE (English / Spanish)
CMS 1938SSO REQUEST FOR CARRIER/INTERMEDIARY ASSISTANCE
CMS 1957SSO REPORT OF STATE BUY IN PROBLEM
CMS 1960REQUEST FOR EVIDENCE OF MEDICAL NECESSITY
CMS 1965REQUEST FOR HEARING – PART B MEDICARE CLAIM
CMS 1980CARRIER OR INTERMEDIARY REQUEST FOR SSO ASSISTANCE
CMS 1984HOSPICE COST REPORT
CMS 20007NOTICE OF EXCLUSIONS FROM MEDICARE BENEFITS (NEMB)
CMS 20014NOTICE OF EXCLUSIONS FROM MEDICARE BENEFITS – SKILLED NURSING FACILITY (NEMB-SNF)
CMS 20017ADVISORY PANEL ON AMBULATORY PAYMENT
CMS 20027MEDICARE REDETERMINATION REQUEST FORM
CMS 20031TRANSFER (ASSIGNMENT) OF APPEAL RIGHTS
CMS 20033MEDICARE RECONSIDERATION REQUEST FORM
CMS 20034A/BREQUEST FOR MEDICARE HEARING BY AN ADMINISTRATIVE LAW JUDGE
CMS 20040Regional Office Meeting/Speaker Request Form
CMS 20041Speech Invitation Request Background Information
CMS 20042Section 1011 Dispute Resolution Request
CMS 2007PROVIDER TIE IN NOTICE
CMS 2088-92OUTPATIENT REHAB PROVIDER COST REPORT
CMS 209LABORATORY PERSONNEL REPORT (CLIA)
CMS 216ORGAN PROCUREMENT ORGANIZATION-HISTO-COMPATIBILITY LAB STATEMENT OF REIMBURSABLE COSTS
CMS 2178HI/SMI ENTITLEMENT PROBLEM REFERRAL
CMS 222INDEPENDENT RURAL HEALTH CLINIC WORKSHEET
CMS 2384THIRD PARTY PREMIUM BILLING REQUEST, MEDICARE
CMS 2501RECONSIDERATION DETERMINATION
CMS 2540-96SNF AND SNF HEALTH CARE COMPLEX COST REPORT
CMS 2540S-97SNF AND SNF HEALTH CARE COMPLEX COST REPORT
CMS 2552-96COST REPORT FOR ELECTRONIC FILING OF HOSPITALS
CMS 2567BPOST-CERTIFICATION REVISIT REPORT
CMS 2628 (35 KB)Foreign HI Claim or Emergency Services Accessibility Documentation and Determination
CMS 265INDEPENDENT RENAL DIALYSIS FACILITY COST REPORT
CMS 2690REQ FOR CANCELLATION OF SMI
CMS 2728ESRD MEDICAL EVIDENCE REPORT MEDICARE ENTITLEMENT AND/OR PATIENT REGISTRATION
CMS 2744AESRD FACILITY SURVEY (DIALYSIS UNIT ONLY)
CMS 2744BEND STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM ESRD FACILITY SURVEY (TRANSPLANT CENTERS ONLY)
CMS 2746ESRD DEATH NOTIFICATION
CMS 2786MFIRE SAFETY SURVEY – RATING RESIDENTS – 2000 CODE
CMS 2786RFIRE SAFETY SURVEY REPORT 2000 CODE – HEALTH CARE – MEDICARE – MEDICAID
CMS 2786SFIRE SAFETY SURVEY REPORT SHORT FORM – MEDICARE – MEDICAID
CMS 2786TFIRE/SMOKE ZONE EVALUATION WORKSHEET FOR HEALTH CARE FACILITIES – 2000 CODE
CMS 2786UFIRE SAFETY SURVEY REPORT – AMBULATORY SURGICAL CENTERS – MEDICARE – 2000 CODE
CMS 2786VFIRE SAFETY SURVEY REPORT ICF/MR – SMALL FACILITIES – 2000 CODE
CMS 2786WFIRE SAFETY SURVEY REPORT – ICF/MR – LARGE FACILITIES – 2000 CODE
CMS 2786XREPORT – ICF/MR APARTMENT HOUSE – 2000 CODE
CMS 2786YFIRE SAFETY SURVEY REPORT ICF/MR – SMALL FSES – 2000 CODE
CMS 2802REQUEST FOR VALIDATION OF ACCREDITATION
CMS 2802BREQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR HOSPICE
CMS 2802CREQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR HOME HEALTH AGENCY
CMS 2802DREQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR AMBULATORY SURGICAL CENTER
CMS 2802EREQUEST FOR VALIDATION OF ACCREDITATION FOR CRITICAL ACCESS HOSPITAL SURVEY
CMS 287HOME OFFICE COST STATEMENT
CMS 2878ACCREDITED HOSPITAL ALLEGATIONS REPORT
CMS 29REQUEST TO ESTABLISH ELIGIBILITY TO PARTICIPATE IN HI FOR AGED/DISABLED TO PROVIDE RURAL HEALTH CLINIC SERVICES
CMS 30RURAL HEALTH CLINIC SURVEY REPORT
CMS 3070GICF/MR SURVEY REPORT
CMS 3070HICF/MR DEFICIENCIES REPORT
CMS 3070IINDIVIDUAL OBSERVATION WORKSHEET
CMS 339PROVIDER COST REPORT REIMBURSEMENT QUESTIONNAIRE
CMS 3427ESRD APPLICATION/NOTIFICATION AND SURVEY/CERTIFICATION REPORT
CMS 3509ALJ MEDICARE CASE FOLDER (CMS)
CMS 352PART A RECONSIDERATION INPUT RECORD
CMS 353PART A PREHEARING INPUT RECORD
CMS 359CORF REPORT FOR CERTIFICATION TO PARTICIPATE IN MEDICARE
CMS 36CONSENT FOR HOME VISIT (English/Spanish)
CMS 360CORF SURVEY REPORT
CMS 36PCONSENT FOR HOME VISIT FOR PACE SERVICES EVALUATION
CMS 370HEALTH INSURANCE BENEFITS AGREEMENT-AMBULATORY SURGICAL CENTER
CMS 377AMBULATORY SURGICAL CENTER REQUEST FOR CERTIFICATION IN MEDICARE
CMS 378AMBULATORY SURGICAL CENTER SURVEY REPORT
CMS 379FINANCIAL STATEMENT OF DEBTOR
CMS 381MODEL LETTER REQUESTING IDENTIFICATION OF EXTENSION LOCATIONS
CMS 382ESRD BENEFICIARY SELECTION
CMS 383HEALTH INSURANCE CASE SUMMARY
CMS 383HEALTH INSURANCE CASE SUMMARY
CMS 384QIO CASE SUMMARY
CMS 4040REQUEST FOR ENROLLMENT IN SUPPLEMENTARY MEDICAL INSURANCE (English / Spanish)
CMS 40BAPPLICATION FOR ENROLLMENT IN MEDICARE
CMS 40FAPPLICATION FOR ENROLLMENT IN MEDICAL INS UNDER MEDICARE
CMS 416Early ad Periodic Screening Diagnostic and Treatment Participation Report
CMS 417HOSPICE REQUEST FOR CERTIFICATION IN MEDICARE
CMS 43APPLICATION FOR HEALTH INSURANCE UNDER MEDICARE FOR INDIVIDUAL WITH CHRONIC RENAL DISEASE
CMS 437PSYCHIATRIC UNIT CRITERIA WORKSHEET
CMS 437AREHAB UNIT CRITERIA WORKSHEET
CMS 437BREHAB HOSPITAL CRITERIA WORKSHEET
CMS 460MEDICARE PARTICIPATING PHYSICIAN OR SUPPLIER AGREEMENT
CMS 462ABCLIA ADVERSE ACTION EXTRACT
CMS 462LADVERSE ACTI0N EXTRACT FOR SNFs AND NFs
CMS 484CERTIFICATE OF MEDICAL NECESSITY – Oxygen DME 484.03
CMS 500NOTICE OF MEDICARE PREMIUM PAYMENT DUE (English / Spanish)
CMS 5011A-BREQUEST FOR MEDICARE HEARING BY ADMINISTRATIVE LAW JUDGE
CMS 562Medicare/Medicaid/CLIA Complaint Form
CMS 576Organ Procurement Request for Designation as an OPO
CMS 576AHealth Insurance Benefits Agreement with Organ Procurement Organization
CMS 588Electronic Funds Transfer (EFT) Authorization Agreement
CMS 632FOIFREEDOM OF INFORMATION ACT REQUEST
CMS 633Invoice of Fees for FOIA Services
CMS 636TRANSMITTAL NOTICE HEARING CASE
CMS 643 (28 KB)Hospice Survey AND Deficiencies Report
CMS 668BPost Lab Survey – CLIA
CMS 671LTC Facility Application for Medicare/Medicaid
CMS 672Resident Census and Conditions of Residents
CMS 673Extended/Partial Extended Survey Worksheet
CMS 677Medication Pass Worksheet
CMS 700Plan of Treatment for Outpatient Rehab
CMS 701Updated Plan of Progress for Outpatient Rehab
CMS 724Medicare/Medicaid Psychiatric Hospital Survey Data
CMS 725Surveyor Worksheet for Psychiatric Hospital Review:Two Special Conditions
CMS 726CMS Death Record Review Data Sheet
CMS 727CMS Nursing Complement Data
CMS 728CMS Staff Data
CMS 729Data Collection Medical Staff Coverage
CMS 801Offsite Survey Prep Worksheet
CMS 802Roster/Sample Matrix
CMS 802PRoster/Sample Matrix Provider Instructions
CMS 802SRoster/Sample Matrix Instruction for Surveyors
CMS 803General Observations of Facility
CMS 804Kitchen/Food Service Observation
CMS 805Resident Review Worksheet
CMS 806AQuality of Life Assessment–Resident
CMS 806BQuality of Life Assessment–Group
CMS 806CQuality of Life Assessment–Family
CMS 807Surveyor Notes Worksheet
CMS 820IN-CENTER HEMODIALYSIS (HD) CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2005
CMS 821PERITONEAL DIALYSIS CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2005
CMS 838Medicare Credit Balance Reporting Requirements
CMS 846Certificate of Medical Necessity – Pneumatic Compression Devices DME 04.04B
CMS 847Certificate of Medical Necessity – Osteogenesis Stimulators – DME 04.04C
CMS 848Certificate of Medical Necessity – Transcutaneous Electrical Nerve Stimulator (TENS) – DME 06.03B
CMS 849Certificate of Medical Necessity – Seat Lift Mechanisms – DME 07.03A
CMS 854Certificate of Medical Necessity – DME 11.02
CMS 855AMedicare Enrollment Application – Institutional Providers
CMS 855BMedicare Enrollment Application – Clinics/Group Practices and Certain Other Suppliers
CMS 855IMedicare Enrollment Application – Physicians and Non-Physician Practitioners
CMS 855RMedicare Enrollment Application – Reassignment of Medicare Benefits
CMS 855SMedicare Enrollment Application – Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers
CMS L457ACKNOWLEDGMENT OF REQUEST FOR MEDICARE MEDICAL INSURANCE TERMINATION
CMS L458ACKNOWLEDGMENT OF REQUEST FOR PREMIUM HOSPITAL INSURANCE TERMINATION
CMS L564Medicare Information
CMS R-0235 (66 KB)Data Use Agreement (DUA) (Agreement for use of Centers for Medicare and Medicaid Services (CMS) data containing individual-specific information
CMS R-0235A (35 KB)Addendum to Data Use Agreement (DUA)
CMS R-0235D1DSH Data Use Agreement
CMS R-0235D2DSH Data Use Agreement for Cost Reporting Periods That Include December 8, 2004 and Thereafter
CMS R-0235L (64 KB)Data Use Agreement (DUA)- Limited Data Sets
CMS R-0235MMedicaid Agency Data Use Agreement
CMS R-0235MAAddendum to the Medicaid State Agency Data Use Agreement
CMS R-0235MCCompliance Plan for Accounting for Disclosures of Privacy Protected Data Released From a System of Records (SOR) Housed in a State-Located Server
CMS R-0235STState Data Use Agreement
CMS R-0235U (48 KB)Data Use Agreement (DUA)- Update to Existing DUA
CMS R-131ADVANCE BENEFICIARY NOTICE (ABN)
CMS R-193IMPORTANT MESSAGE FROM MEDICARE (IM)
CMS R-285Request for Retirement Benefit Information
CMS R-296HOME HEALTH ADVANCE BENEFICIARY NOTICE
HCFA 378EAMBULATORY SURGICAL CTR REPORT–CRUCIAL DATA EXTRACT

Source: http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp?intNumPerPage=all&submit=Go


Inside Department of Health and Human Services