U.S. Department of Health and Human Services Forms

This form is used for conducting site investigations at independent diagnostic testing facilities. It helps gather information about the facility's location, equipment, and personnel to ensure compliance with CMS regulations.

This Form is used for reporting credit balances to Medicare, which refers to overpayments that need to be refunded. It helps healthcare providers accurately calculate and reconcile outstanding credit balances.

This form is used for entering into a data use agreement for limited data sets under CMS-R-0235L.

This form is used for agreeing to use Centers for Medicare and Medicaid Services (CMS) data containing individual identifiers.

This form is used for conducting surveys on End Stage Renal Disease (ESRD) facilities that provide dialysis treatment. It helps gather medical information about these facilities.

This Form is used for submitting a Medicare Reconsideration Request at the 2nd Level of Appeal. It allows individuals to request a review of a previous Medicare determination made by Medicare Administrative Contractors (MACs) or other entities.

This form is used for healthcare providers to apply for enrollment in the Medicare program.

This form is used to collect medical information about end stage renal disease (ESRD) facilities that also serve as transplant centers.

This form is used for requesting a redetermination for a Medicare claim. It is the first step in the appeals process.

This document provides a priority chart for the IHS Loan Repayment Program. It outlines the order in which applications are reviewed and prioritized.

This document provides a priority chart for the IHS Scholarship Program.

This Form is used for reporting cases of pediatric deaths associated with influenza. It helps track and analyze the data to understand the impact of influenza on children.

This form is used for reporting cases of Multisystem Inflammatory Syndrome associated with Covid-19. It provides instructions on how to fill out the necessary information for reporting and documenting these cases.

This document is a goal setting worksheet to help you define and track your goals. Use it to clarify your objectives, set action steps, and measure your progress.

This document is used for assessing the health of CDC employees and capturing important information.

This Form is used for collecting inputs for the CDC National Health and Wellness Promotion's Health and Safety Climate Survey.

This document is a questionnaire used for collecting information on hepatitis D, a viral infection that affects the liver.

This form is used for reporting verified cases of tuberculosis to the Centers for Disease Control and Prevention. It provides important information about the individual diagnosed with tuberculosis and helps in tracking and monitoring the spread of the disease.

This Form is used for recording information about pediatric palliative care in Spanish language.

This Form is used for filing a Notice of Denial of Medical Coverage for recipients of Non-Dual Medicare and Medicaid Coverage Plans. It provides instructions for completing and submitting the form.

This document is for requesting an extension of a facility and providing progress updates. It helps keep track of the progress and communicate any changes or delays in the project.

This article provides information on the Modifier 59, which is used in medical coding to identify distinct procedures or services that are not typically reported together. It explains its purpose, guidelines, and importance in accurate billing and coding.

This document is a compilation of resources related to hospitals and COVID-19. It provides information on testing, treatment options, and support services available during the pandemic.

This form is used for applying for federal assistance in the United States. It is used to request financial aid or resources from the government for various purposes. The SF-24 is a standard application form that collects relevant information and documentation required for the evaluation and processing of the application.

This form is used for collecting and documenting patient information for possible human rabies cases.

This Form is used for recording information related to Tularemia cases during an investigation.

This document is a worksheet used for monitoring and tracking cases of measles. It helps healthcare professionals gather important information about individuals who have been affected by the disease.

This Form is used for reporting cases of Tickborne Rickettsial Disease.