Documents
![Form CMS L564 "Request for Employment Information"](https://data.templateroller.com/pdf_docs_html/2083/20839/2083997/form-cms-l564-r297-request-for-employment-information.png "Form CMS L564 "Request for Employment Information"")
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"](https://data.templateroller.com/pdf_docs_html/46/467/46702/form-cms-853-certificate-medical-necessity.png "Form CMS-853 "Certificate of Medical Necessity"")
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](https://data.templateroller.com/pdf_docs_html/2188/21886/2188623/form-lic9163-request-for-live-scan-service-community-care-licensing-california.png "Form LIC9163 "Request for Live Scan Service - Community Care Licensing" - California")
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"](https://data.templateroller.com/pdf_docs_html/243/2433/243346/modified-berthel-index-shah-version-self-care-assessment-form.png ""Modified Berthel Index (Shah Version) - Self Care Assessment Form"")
"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](https://data.templateroller.com/pdf_docs_html/98/981/98195/mini-mental-state-examination-mmse-form-iowa.png ""Mini-Mental State Examination (Mmse) Form" - Iowa")
"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 33 "Safety and Health Program Assessment Worksheet" - California](https://data.templateroller.com/pdf_docs_html/162/1620/162025/form-33-safety-and-health-program-assessment-worksheet-california.png "Form 33 "Safety and Health Program Assessment Worksheet" - California")
![Formulario CMS-L564 "Solicitud De Informacion Sobre El Empleo" (Spanish)](https://data.templateroller.com/pdf_docs_html/1742/17424/1742498/form-cms-l564-solicitud-de-informacion-sobre-el-empleo.png "Formulario CMS-L564 "Solicitud De Informacion Sobre El Empleo" (Spanish)")
![Form CMS-804 "Kitchen/Food Service Observation"](https://data.templateroller.com/pdf_docs_html/606/6062/606237/form-cms-804-kitchen-food-service-observation.png "Form CMS-804 "Kitchen/Food Service Observation"")
![Form CMS-437 "Psychiatric Unit Criteria Worksheet"](https://data.templateroller.com/pdf_docs_html/617/6177/617784/form-cms-437-psychiatric-unit-criteria-worksheet.png "Form CMS-437 "Psychiatric Unit Criteria Worksheet"")
![Form CMS-209 "Laboratory Personnel Report (Clia)"](https://data.templateroller.com/pdf_docs_html/1899/18992/1899247/form-cms-209-laboratory-personnel-report-clia.png "Form CMS-209 "Laboratory Personnel Report (Clia)"")
![Form 214 "Medicaid Agency Statement of Intent to Return Home" - Alabama](https://data.templateroller.com/pdf_docs_html/72/727/72735/form-214-medicaid-agency-statement-intent-to-return-home-alabama.png "Form 214 "Medicaid Agency Statement of Intent to Return Home" - Alabama")
![Form MC371 "Additional Family Members Requesting Medical" - California](https://data.templateroller.com/pdf_docs_html/48/483/48354/form-mc-371-additional-family-members-requesting-medical-california.png "Form MC371 "Additional Family Members Requesting Medical" - California")
![Form DOH-132 "Wic Medical Referral Form for Infants and Children" - New York](https://data.templateroller.com/pdf_docs_html/328/3289/328986/form-doh-132-wic-medical-referral-form-infants-and-children-new-york.png "Form DOH-132 "Wic Medical Referral Form for Infants and Children" - New York")
![Form DOH-799 "Wic Medical Referral Form" - New York](https://data.templateroller.com/pdf_docs_html/1729/17292/1729229/form-doh-799-wic-medical-referral-form-new-york.png "Form DOH-799 "Wic Medical Referral Form" - New York")
![Form CMS-437B "Rehabilitation Hospital Criteria Work Sheet"](https://data.templateroller.com/pdf_docs_html/1899/18992/1899250/form-cms-437b-rehabilitation-hospital-criteria-work-sheet.png "Form CMS-437B "Rehabilitation Hospital Criteria Work Sheet"")
![Form 5021 "Doctors First Report of Occupational Injury or Illness" - California](https://data.templateroller.com/pdf_docs_html/74/744/74410/form-5021-doctors-first-report-occupational-injury-or-illness-california.png "Form 5021 "Doctors First Report of Occupational Injury or Illness" - California")
Form 5021 "Doctors First Report of Occupational Injury or Illness" - California
![Form DH3075 "Florida Wic Program Medical Referral Form" - Florida](https://data.templateroller.com/pdf_docs_html/328/3289/328977/form-dh-3075-florida-wic-program-medical-referral-form-florida.png "Form DH3075 "Florida Wic Program Medical Referral Form" - Florida")
![Form 3231 "Certificate of Immunization" - Georgia (United States)](https://data.templateroller.com/pdf_docs_html/241/2411/241171/form-3231-certificate-immunization-georgia-united-states.png "Form 3231 "Certificate of Immunization" - Georgia (United States)")
![Form DCH-1326 "Wic Special Formula/Food Request" - Michigan](https://data.templateroller.com/pdf_docs_html/2267/22676/2267612/form-dch-1326-wic-special-formula-food-request-michigan.png "Form DCH-1326 "Wic Special Formula/Food Request" - Michigan")
![Form CMS-2786U "Fire Safety Survey Report - 2012 Life Safety Code Ambulatory Health Care"](https://data.templateroller.com/pdf_docs_html/1744/17448/1744810/form-cms-2786u-fire-safety-survey-report-2012-life-safety-code-ambulatory-health-care.png "Form CMS-2786U "Fire Safety Survey Report - 2012 Life Safety Code Ambulatory Health Care"")
![Form CMS-2786R "Fire Safety Survey Report - Healthcare - 2012 Life Safety Code"](https://data.templateroller.com/pdf_docs_html/1744/17448/1744813/form-cms-2786r-fire-safety-survey-report-healthcare-2012-life-safety-code.png "Form CMS-2786R "Fire Safety Survey Report - Healthcare - 2012 Life Safety Code"")
![Form ODM06653 "Medical Claim Review Request" - Ohio](https://data.templateroller.com/pdf_docs_html/597/5979/597916/form-odm-06653-medical-claim-review-request-ohio.png "Form ODM06653 "Medical Claim Review Request" - Ohio")
![NAVMED Form 6000/5 "Vaccine Screening Questionnaire"](https://data.templateroller.com/pdf_docs_html/48/488/48879/navmed-form-6000-5-vaccine-screening-questionnaire.png "NAVMED Form 6000/5 "Vaccine Screening Questionnaire"")
![Form CMS-r-0235u "Agreement for Use of Centers for Medicare & Medicaid Services (Cms) Data"](https://data.templateroller.com/pdf_docs_html/617/6178/617800/form-cms-r-0235u-agreement-use-centers-medicare-medicaid-services-cms-data.png "Form CMS-r-0235u "Agreement for Use of Centers for Medicare & Medicaid Services (Cms) Data"")
![Form CF-es 2282 "Medicaid/Medicare Buy-In Application" - Florida](https://data.templateroller.com/pdf_docs_html/304/3040/304007/form-cf-es-2282-medicaid-medicare-buy-in-application-florida.png "Form CF-es 2282 "Medicaid/Medicare Buy-In Application" - Florida")
![DSHS Form 13-585a "Range of Joint Motion Evaluation Chart" - Washington](https://data.templateroller.com/pdf_docs_html/213/2131/213185/dshs-form-13-585a-range-joint-motion-evaluation-chart-washington.png "DSHS Form 13-585a "Range of Joint Motion Evaluation Chart" - Washington")
![Form UCSMM.URV.06.14.A1 "Out of Network Prior Authorization Request - Unitedhealthcare"](https://data.templateroller.com/pdf_docs_html/319/3193/319340/form-ucsmm-urv-06-14-a1-out-network-prior-authorization-request-unitedhealthcare.png "Form UCSMM.URV.06.14.A1 "Out of Network Prior Authorization Request - Unitedhealthcare"")
![Form MS014.1607 "Medicare Claim" - Australia](https://data.templateroller.com/pdf_docs_html/2/21/2164/form-ms014-1607-medicare-claim-australia.png "Form MS014.1607 "Medicare Claim" - Australia")
![Form 82160-Flu "Claim Form - Flu Shot Only - Anthem Blue Cross and Blue Shield" - Colorado](https://data.templateroller.com/pdf_docs_html/479/4795/479547/form-82160-flu-claim-form-flu-shot-only-anthem-blue-cross-and-blue-shield-colorado.png "Form 82160-Flu "Claim Form - Flu Shot Only - Anthem Blue Cross and Blue Shield" - Colorado")
![Form F242-385-000 "Activity Prescription Form (Apf)" - Washington](https://data.templateroller.com/pdf_docs_html/1909/19090/1909041/form-f-242-385-000-activity-prescription-form-apf-washington.png "Form F242-385-000 "Activity Prescription Form (Apf)" - Washington")
![Form 2335a_20121213 "Prior Authorization Fax Request Form - Unitedhealthcare" - Washington](https://data.templateroller.com/pdf_docs_html/368/3688/368887/form-2335a-20121213-prior-authorization-fax-request-form-unitedhealthcare-washington.png "Form 2335a_20121213 "Prior Authorization Fax Request Form - Unitedhealthcare" - Washington")
!["Hepatitis B Vaccination Declination Form"](https://data.templateroller.com/pdf_docs_html/48/487/48795/hepatitis-b-vaccination-declination-form.png ""Hepatitis B Vaccination Declination Form"")
!["Medical Documentation Form for Wic Special Formulas and Wic Foods" - Georgia (United States)](https://data.templateroller.com/pdf_docs_html/248/2488/248865/medical-documentation-form-wic-special-formulas-and-wic-foods-georgia-united-states.png ""Medical Documentation Form for Wic Special Formulas and Wic Foods" - Georgia (United States)")
!["Wic Program Medical Documentation Form" - Maryland](https://data.templateroller.com/pdf_docs_html/328/3289/328955/wic-program-medical-documentation-form-maryland.png ""Wic Program Medical Documentation Form" - Maryland")
!["Appeal Request Form - Mnsure" - Minnesota](https://data.templateroller.com/pdf_docs_html/1734/17347/1734785/appeal-request-form-mnsure-minnesota.png ""Appeal Request Form - Mnsure" - Minnesota")
!["Minnesota Health Insurance Exchange Project Issues Log" - Minnesota](https://data.templateroller.com/pdf_docs_html/1734/17342/1734299/minnesota-health-insurance-exchange-project-issues-log-minnesota.png ""Minnesota Health Insurance Exchange Project Issues Log" - Minnesota")
!["Health Care Proxy Form" - New York](https://data.templateroller.com/pdf_docs_html/33/332/33229/health-care-proxy-form-new-york.png ""Health Care Proxy Form" - New York")
!["Well Child Exam Template - Early Childhood 18 Month" - Ohio](https://data.templateroller.com/pdf_docs_html/73/735/73545/well-child-exam-template-early-childhood-18-month-ohio.png ""Well Child Exam Template - Early Childhood 18 Month" - Ohio")
!["Well Child Exam Template - Infancy 9 Month" - Ohio](https://data.templateroller.com/pdf_docs_html/82/825/82576/well-child-exam-template-infancy-9-month-ohio.png ""Well Child Exam Template - Infancy 9 Month" - Ohio")
!["Well Child Exam Template - Infancy Newborn 1 Week Visit" - Ohio](https://data.templateroller.com/pdf_docs_html/82/825/82583/well-child-exam-template-infancy-newborn-1-week-visit-ohio.png ""Well Child Exam Template - Infancy Newborn 1 Week Visit" - Ohio")
