U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services Forms

The U.S. Department of Health and Human Services (HHS) - Centers for Medicare and Medicaid Services (CMS) is responsible for administering two key healthcare programs in the United States. Medicare is a federal program that provides health insurance coverage to individuals who are 65 years old or older, as well as certain younger individuals with disabilities. Medicaid is a joint federal and state program that offers healthcare coverage to low-income individuals, including children, pregnant women, elderly adults, and people with disabilities. The CMS works to ensure that these programs are effectively implemented and that beneficiaries have access to the healthcare services they need.




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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.

This form is filled out by the patient's attending physician and used as a fiduciary document in order to authorize professional health services.

This Form is used for observing and evaluating the kitchen and food service areas in healthcare facilities to ensure compliance with relevant regulations and standards.

This form is used for applying for a Medicare waiver demonstration, allowing individuals to access certain healthcare services.


This form is used for gathering information about the residents and their conditions in a healthcare facility. It helps in maintaining accurate records and ensuring the well-being of the residents.

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.

This Form is used for submitting hospital claims to Medicare and Medicaid. It includes information on the services provided and the charges associated with them.

This form is used for applying and reporting end stage renal disease (ESRD) services. It is designed for healthcare providers to apply for ESRD certification and submit survey and certification reports.

This form is used for requesting third party premium billing for Medicare services. It allows the individual or organization to request payment directly from a third party payer for services provided to Medicare beneficiaries.

This form is used for the transfer of appeal rights in the CMS-20031 form. It allows individuals to transfer their rights to appeal a decision to someone else.

This is a document developed for nursing facilities which are supposed to be filed during standard or extended health surveys.

Medicare beneficiaries may use this form to authorize individuals or organizations they trust to examine their medical records and learn their protected health information.

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.

Este formulario se utiliza para que los pacientes realicen una petición de pago a Medicare. (This form is used for patients to request payment from Medicare)

This form is used for reporting deaths in hospitals that are associated with the use of restraints or seclusion.

This form is used for conducting a fire safety survey for intermediate care facilities with intellectual disabilities that are apartment houses. It follows the 2012 Life Safety Code.

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