Documents
33
![Form CMS-671 "Long-Term Care Facility Application for Medicare and Medicaid"](https://data.templateroller.com/pdf_docs_html/1744/17447/1744779/form-cms-671-long-term-care-facility-application-medicare-and-medicaid.png "Form CMS-671 "Long-Term Care Facility Application for Medicare and Medicaid"")
Form CMS-671 "Long-Term Care Facility Application for Medicare and Medicaid"
Size: 66 KB
3 pages
This is a document developed for nursing facilities which are supposed to be filed during standard or extended health surveys.
![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.
![Form CMS-1763 "Request for Termination of Premium Hospital and/Or Supplementary Medical Insurance"](https://data.templateroller.com/pdf_docs_html/1744/17447/1744794/form-cms-1763-request-termination-premium-hospital-and-or-supplementary-medical-insurance.png "Form CMS-1763 "Request for Termination of Premium Hospital and/Or Supplementary Medical Insurance"")
Form CMS-1763 "Request for Termination of Premium Hospital and/Or Supplementary Medical Insurance"
Size: 65 KB
1 page
This is a legal document that any Medicare enrollee may use to terminate hospital insurance and supplementary medical insurance. This form was released by the U.S. Department of Health and Human Services.
![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-802 "Matrix for Providers"](https://data.templateroller.com/pdf_docs_html/1728/17289/1728975/form-cms-802-matrix-providers.png "Form CMS-802 "Matrix for Providers"")
![Form CMS-848 "Certificate of Medical Necessity - Transcutaneous Electrical Nerve Stimulator (Tens)"](https://data.templateroller.com/pdf_docs_html/1729/17292/1729280/form-cms-848-certificate-medical-necessity-transcutaneous-electrical-nerve-stimulator-tens.png "Form CMS-848 "Certificate of Medical Necessity - Transcutaneous Electrical Nerve Stimulator (Tens)"")
![Form CMS-846 "Certificate of Medical Necessity - Pneumatic Compression Devices"](https://data.templateroller.com/pdf_docs_html/1729/17292/1729279/form-cms-846-certificate-medical-necessity-pneumatic-compression-devices.png "Form CMS-846 "Certificate of Medical Necessity - Pneumatic Compression Devices"")
Form CMS-846 "Certificate of Medical Necessity - Pneumatic Compression Devices"
Size: 108 KB
2 pages
![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-381 "Model Letter Requesting Identification of Extension Locations"](https://data.templateroller.com/pdf_docs_html/1744/17448/1744803/form-cms-381-model-letter-requesting-identification-extension-locations.png "Form CMS-381 "Model Letter Requesting Identification of Extension Locations"")
![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-1557 "Survey Report Form (Clia)"](https://data.templateroller.com/pdf_docs_html/1899/18992/1899240/form-cms-1557-survey-report-form-clia.png "Form CMS-1557 "Survey Report Form (Clia)"")
![Form CMS1696 "Appointment of Representative - Large Print"](https://data.templateroller.com/pdf_docs_html/1899/18992/1899243/form-cms-1696-appointment-representative-large-print.png "Form CMS1696 "Appointment of Representative - Large Print"")
![Form CMS-1696 "Appointment of Representative"](https://data.templateroller.com/pdf_docs_html/1899/18992/1899242/form-cms-1696-appointment-representative.png "Form CMS-1696 "Appointment of Representative"")
![Formulario CMS-1696 "Nombramiento De Un Representante" (Spanish)](https://data.templateroller.com/pdf_docs_html/1899/18992/1899241/form-cms-1696-nombramiento-de-un-representante.png "Formulario CMS-1696 "Nombramiento De Un Representante" (Spanish)")
![Form CMS-1957 "Sso Report of State Buy-In Problem"](https://data.templateroller.com/pdf_docs_html/1899/18992/1899245/form-cms-1957-sso-report-state-buy-in-problem.png "Form CMS-1957 "Sso Report of State Buy-In Problem"")
![Form CMS-2384 "Third Party Premium Billing Request"](https://data.templateroller.com/pdf_docs_html/1744/17447/1744774/form-cms-2384-third-party-premium-billing-request.png "Form CMS-2384 "Third Party Premium Billing Request"")
![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-2786X "Fire Safety Survey Report - Intermediate Care Facilities With Intellectual Disabilities (Apartment House) - 2012 Life Safety Code"](https://data.templateroller.com/pdf_docs_html/1744/17448/1744805/form-cms-2786x-fire-safety-survey-report-intermediate-care-facilities-with-intellectual-disabilities-apartment-house-2012-life-safety-code.png "Form CMS-2786X "Fire Safety Survey Report - Intermediate Care Facilities With Intellectual Disabilities (Apartment House) - 2012 Life Safety Code"")
![Form CMS-2786W "Fire Safety Survey Report - Intermediate Care Facilities for Individuals With Intellectual Disabilities (Large Facilities) - 2012 Life Safety Code"](https://data.templateroller.com/pdf_docs_html/1744/17448/1744806/form-cms-2786w-fire-safety-survey-report-intermediate-care-facilities-individuals-with-intellectual-disabilities-large-facilities-2012-life-safety-code.png "Form CMS-2786W "Fire Safety Survey Report - Intermediate Care Facilities for Individuals With Intellectual Disabilities (Large Facilities) - 2012 Life Safety Code"")
![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-2786Y "Fire Safety Evaluation System - Intermediate Care Facilities for Individuals With Intellectual Disabilities (Small Facilities) - 2012 Life Safety Code"](https://data.templateroller.com/pdf_docs_html/1744/17447/1744789/form-cms-2786y-fire-safety-evaluation-system-intermediate-care-facilities-individuals-with-intellectual-disabilities-small-facilities-2012-life-safety-code.png "Form CMS-2786Y "Fire Safety Evaluation System - Intermediate Care Facilities for Individuals With Intellectual Disabilities (Small Facilities) - 2012 Life Safety Code"")
![Form CMS-2786M "Worksheet for Determining Evacuation Capability - Intermediate Care Facilities for Individuals With Intellectual Disabilities (Existing Facilities Only) - 2012 Life Safety Code"](https://data.templateroller.com/pdf_docs_html/1744/17447/1744791/form-cms-2786m-worksheet-determining-evacuation-capability-intermediate-care-facilities-individuals-with-intellectual-disabilities-existing-facilities-only-2012-life-safety-code.png "Form CMS-2786M "Worksheet for Determining Evacuation Capability - Intermediate Care Facilities for Individuals With Intellectual Disabilities (Existing Facilities Only) - 2012 Life Safety Code"")
![Form CMS-2786T "Fire Safety Evaluation System - Health Care Facilities - 2012 Life Safety Code"](https://data.templateroller.com/pdf_docs_html/1744/17447/1744792/form-cms-2786t-fire-safety-evaluation-system-health-care-facilities-2012-life-safety-code.png "Form CMS-2786T "Fire Safety Evaluation System - Health Care Facilities - 2012 Life Safety Code"")
![Form CMS-2786V "Fire Safety Survey Report - Intermediate Care Facilities for Individuals With Intellectual Disabilities (Small Facilities) - 2012 Life Safety Code"](https://data.templateroller.com/pdf_docs_html/1744/17448/1744811/form-cms-2786v-fire-safety-survey-report-intermediate-care-facilities-individuals-with-intellectual-disabilities-small-facilities-2012-life-safety-code.png "Form CMS-2786V "Fire Safety Survey Report - Intermediate Care Facilities for Individuals With Intellectual Disabilities (Small Facilities) - 2012 Life Safety Code"")
![Form CMS-10114 "National Provider Identifier (Npi) Application/Update Form"](https://data.templateroller.com/pdf_docs_html/1899/18992/1899244/form-cms-10114-national-provider-identifier-npi-application-update-form.png "Form CMS-10114 "National Provider Identifier (Npi) Application/Update Form"")
![Form CMS-20031 "Transfer of Appeal Rights"](https://data.templateroller.com/pdf_docs_html/1744/17447/1744778/form-cms-20031-transfer-appeal-rights.png "Form CMS-20031 "Transfer of Appeal Rights"")
![Form CMS-10455 "Report of a Hospital Death Associated With Restraint or Seclusion"](https://data.templateroller.com/pdf_docs_html/1744/17448/1744804/form-cms-10455-report-a-hospital-death-associated-with-restraint-or-seclusion.png "Form CMS-10455 "Report of a Hospital Death Associated With Restraint or Seclusion"")
![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"")
!["Medicare Authorization Form"](https://data.templateroller.com/pdf_docs_html/1899/18992/1899255/medicare-authorization-form.png ""Medicare Authorization Form"")
