Documents
Form CMS L564 "Request for Employment Information"
This is a legal document which must be completed to prove the group health plan coverage based on your or your spouse's current employment.
Form CMS-853 "Certificate of Medical Necessity"
File this form to document that the use of the medical equipment used for enteral nutrition is justified. This part of the procedure is called the medical necessity, which is a way to have Medicare compensate the costs of items and services that are considered necessary.
Form LIC9163 "Request for Live Scan Service - Community Care Licensing" - California
This form must be completed if you wish to work at, be licensed, or present at a licensed community care facility or organization.
"Modified Berthel Index (Shah Version) - Self Care Assessment Form"
Use this simple and convenient tool called Barthel index scale for self-evaluation of everyday activities and abilities. The form is a four-page document that consists of a table for a self-care assessment and two tables for an interpretation of the results.
"Mini-Mental State Examination (Mmse) Form" - Iowa
This MMSE form is a three-page document that allows to measure any cognitive impairments a patient may have and to record progress over time.
Form 5021 "Doctors First Report of Occupational Injury or Illness" - California
