Documents
14
![Form CMS-L654 "Request for Employment Information"](https://data.templateroller.com/pdf_docs_html/618/6182/618206/form-cms-l564-request-employment-information.png "Form CMS-L654 "Request for Employment Information"")
Form CMS-L654 "Request for Employment Information"
Size: 106 KB
3 pages
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.
![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 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 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 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 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")
!["Medicare Secondary Payer Questionnaire Template - Albany Medical Center"](https://data.templateroller.com/pdf_docs_html/46/466/46673/medicare-secondary-payer-questionnaire-template-albany-medical-center.png ""Medicare Secondary Payer Questionnaire Template - Albany Medical Center"")
!["Medicare Secondary Payer Questionnaire Template"](https://data.templateroller.com/pdf_docs_html/236/2361/236189/medicare-secondary-payer-questionnaire-template.png ""Medicare Secondary Payer Questionnaire Template"")
!["Medicare Secondary Payer Questionnaire Template"](https://data.templateroller.com/pdf_docs_html/236/2361/236191/medicare-secondary-payer-questionnaire-template.png ""Medicare Secondary Payer Questionnaire Template"")
!["Medicare Secondary Payer Questionnaire Template"](https://data.templateroller.com/pdf_docs_html/236/2369/236966/medicare-secondary-payer-questionnaire-template.png ""Medicare Secondary Payer Questionnaire Template"")
