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

This form is used for reporting fire safety surveys in large facilities that provide intermediate care for individuals with intellectual disabilities. It follows the guidelines of the 2012 Life Safety Code.

This form is used for reporting the results of the fire safety survey conducted in ambulatory health care facilities. It follows the guidelines set by the 2012 Life Safety Code.

This Form is used for reporting the results of fire safety surveys in small intermediate care facilities for individuals with intellectual disabilities. It follows the 2012 Life Safety Code guidelines.

This form is used for applying for Medicare enrollment.

This document is a guide that provides information on Medicare Special Needs Plans (SNPs). It explains what SNPs are and the benefits they offer for individuals with specific health needs. It also highlights the eligibility criteria and enrollment process for SNPs.

Medicare is a federal health insurance program in the United States that provides coverage to individuals who are 65 years or older, as well as certain younger individuals with disabilities.

Medicaid is a joint federal and state program in the United States that provides health coverage to low-income individuals and families, including pregnant women, children, and people with disabilities.

This Form is used for requesting approval as a hospital provider of extended care services (swing-bed) in the Medicare and Medicaid programs.

This Form is used for making changes or amendments to the attestation for the Medicare EHR Incentive Program.

This document is a helpful checklist for selecting a nursing home for yourself or a loved one. It outlines key factors to consider, such as staff qualifications, facility cleanliness, and resident safety measures.

This document type is used for organizing episodes of a Content Management System (CMS) related to Macra: Mips & Apms.

This Form is used for understanding Medicare's coverage of diabetes supplies and services. It explains what is covered and how to access the benefits.

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 Form is used for providing consent to appoint a representative to assist with Medicare-related matters in larger print format.

This form is used for reporting state buy-in problems to the Centers for Medicare and Medicaid Services (CMS). It helps to identify and address issues related to the state buy-in program.

This form is used to assess and determine the eligibility criteria for rehabilitation units under the CMS-437A program.

This document is used for authorizing Medicare to release personal health information to a designated individual or organization.

This form is used for patients to request medical payment from CMS.

This Form is used for submitting medical claims for services provided in a hospital or other healthcare facility.

This document explains the Medicare hospice benefits available to individuals who have a terminal illness and are receiving hospice care. It includes information on what services are covered, eligibility requirements, and how to apply.

This Form is used for Advance Beneficiary Notice of Noncoverage (ABN). It is a notice given to Medicare beneficiaries in the United States to inform them that Medicare is not likely to cover a specific service or item, and that they may have to pay for it themselves.

This Form is used for submitting health insurance claims for medical services. It is used by healthcare providers to request payment from insurance companies.

This document is used to apply for a hardship exemption, which could provide relief from certain financial or health-related burdens. It allows individuals to request an exemption from certain requirements, such as a tax penalty or healthcare coverage, due to difficult circumstances they are facing.

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.

This document explains the relationship between Medicare and home health care services. It provides information about what Medicare covers and how to access home health care benefits.

This document provides clinical concepts for family practice based on ICD-10 coding. It covers various medical conditions and their corresponding codes used in family practice.

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

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

This form is used for Medicare Claim Review Programs. It is used to review and process claims made under Medicare.

This document promotes oral health for children and adolescents through the Medicaid benefit. It provides information and guidelines on how to keep kids' teeth healthy.