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

84
total templates

Documents

84

Form CMS-40B "Application for Enrollment in Medicare Part B (Medical Insurance)"

Rate (4.5 / 5) 12 votes
Size: 52 KB
4 pages

This application is supposed to be used by individuals when they want to apply for enrollment in Medicare Part B, insurance which provides outpatient medical coverage.

Form CMS-671 "Long-Term Care Facility Application for Medicare and Medicaid"

Rate (4.8 / 5) 59 votes
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"

Rate (4.6 / 5) 69 votes
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-853 "Certificate of Medical Necessity"

Rate (4.3 / 5) 60 votes
Size: 63 KB
2 pages

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 CMS-485 "Home Health Certification and Plan of Care"

Rate (4.4 / 5) 42 votes
Size: 31 KB
2 pages

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

Form CMS-1763 "Request for Termination of Premium Hospital and/Or Supplementary Medical Insurance"

Rate (4.6 / 5) 99 votes
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.

Sample "Medicaid Renewal Form"

Rate (4.8 / 5) 12 votes
Size: 235 KB
13 pages

File this renewal form annually in order to renew your Medicare coverage.

"Application for Health Coverage & Help Paying Costs"

Rate (4.8 / 5) 8 votes
Size: 1 MB
15 pages

This application is a legal document used to apply for and enroll in Marketplace health coverage with the DHHS.

Form UB-92 (HCFA-1450) "Uniform Bill"

Rate (4.7 / 5) 25 votes
Size: 48 KB
2 pages

Form UB-04 (CMS1450) "Uniform Bill"

Rate (4.3 / 5) 29 votes
Size: 1 MB
2 pages

Formulario CMS-40B "Solicitud De Inscripcion Para Medicare Parte B (Seguro Medico)" (Spanish)

Rate (4.4 / 5) 93 votes
Size: 54 KB
4 pages

Form CMS-484 "Certificate of Medical Necessity - Oxygen"

Rate (4.6 / 5) 55 votes
Size: 2 MB
2 pages

Form CMS-209 "Laboratory Personnel Report (Clia)"

Rate (4.5 / 5) 107 votes
Size: 185 KB
2 pages

Form CMS-802 "Matrix for Providers"

Rate (4.6 / 5) 46 votes
Size: 120 KB
2 pages

Form CMS-116 "Clinical Laboratory Improvement Amendments (Clia) - Application for Certification"

Rate (4.6 / 5) 25 votes
Size: 267 KB
10 pages

Form CMS-849 "Certificate of Medical Necessity - Seat Lift Mechanisms"

Rate (4.3 / 5) 79 votes
Size: 142 KB
2 pages

Form CMS-846 "Certificate of Medical Necessity - Pneumatic Compression Devices"

Rate (4.8 / 5) 36 votes
Size: 108 KB
2 pages

Form CMS-848 "Certificate of Medical Necessity - Transcutaneous Electrical Nerve Stimulator (Tens)"

Rate (4.3 / 5) 77 votes
Size: 133 KB
2 pages

Form CMS-854 "Certificate of Medical Necessity -continuation Form"

Rate (4.8 / 5) 59 votes
Size: 117 KB
2 pages

Form CMS-847 "Certificate of Medical Necessity - Osteogenesis Stimulators"

Rate (4.4 / 5) 44 votes
Size: 179 KB
2 pages

Formulario CMS-L564 "Solicitud De Informacion Sobre El Empleo" (Spanish)

Rate (4.6 / 5) 97 votes
Size: 70 KB
3 pages

Form CMS-L564 "Request for Employment Information"

Rate (4.5 / 5) 21 votes
Size: 62 KB
3 pages

Form CMS-804 "Kitchen/Food Service Observation"

Rate (4.3 / 5) 44 votes
Size: 184 KB
2 pages

Form CMS-672 "Resident Census and Conditions of Residents"

Rate (4.4 / 5) 86 votes
Size: 360 KB
7 pages

Form CMS-381 "Model Letter Requesting Identification of Extension Locations"

Rate (4.7 / 5) 63 votes
Size: 54 KB
1 page

Form CMS-437 "Psychiatric Unit Criteria Worksheet"

Rate (4.8 / 5) 49 votes
Size: 208 KB
8 pages

Form HCFA-605 "Request for Approval as a Hospital Provider of Extended Care Services (Swing-Bed) in the Medicare and Medicaid Programs"

Rate (4.7 / 5) 57 votes
Size: 18 KB
1 page

Form CMS-R285 "Request for Retirement Benefit Information"

Rate (4.5 / 5) 42 votes
Size: 68 KB
1 page

Form CMS-R-131 "Advance Beneficiary Notice of Noncoverage (Abn)"

Rate (4.4 / 5) 31 votes
Size: 47 KB
1 page

Form CMS-437B "Rehabilitation Hospital Criteria Work Sheet"

Rate (4.6 / 5) 121 votes
Size: 171 KB
7 pages

Form CMS-1557 "Survey Report Form (Clia)"

Rate (4.7 / 5) 97 votes
Size: 1 MB
4 pages

Form CMS-855I "Medicare Enrollment Application - Physicians and Non-physician Practitioners"

Rate (4.6 / 5) 102 votes
Size: 374 KB
25 pages

Form CMS1696 "Appointment of Representative - Large Print"

Rate (4.4 / 5) 63 votes
Size: 27 KB
8 pages

Form CMS-1696 "Appointment of Representative"

Rate (4.3 / 5) 56 votes
Size: 73 KB
2 pages

Formulario CMS-1696 "Nombramiento De Un Representante" (Spanish)

Rate (4.8 / 5) 42 votes
Size: 47 KB
2 pages

Form CMS-1957 "Sso Report of State Buy-In Problem"

Rate (4.5 / 5) 82 votes
Size: 233 KB
2 pages

Form CMS-2384 "Third Party Premium Billing Request"

Rate (4.6 / 5) 94 votes
Size: 57 KB
1 page