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CMS Forms

The Centers for Medicare & Medicaid Services (CMS) is a Federal agency within the U.S. Department of Health and Human Services. Programs for which CMS is responsible include Medicare, Medicaid, State Children's Health Insurance Program(SCHIP), HIPAA , and CLIA.

CMS is making many of its Program Forms available in Portable Document Format (PDF) for informational purposes. The forms that are currently available electronically are underlined in blue in the list below. CMS is committed to promoting the goals of the Web Accessibility Initiative and Section 508. Information is provided on various file formats and plug-ins.

Hard copy forms continue to be available from the Intermediary, Carrier, State Agency, local Social Security Field Office or End Stage Renal Disease Network that services your State. The Contact column of the forms list identifies your contact for obtaining hard copies of the form. These groups can also assist you with completion of the form. If you have difficulty obtaining copies from these groups, please contact your local CMS Regional Office.

For your convenience, links to Optional Forms, Standard Forms, SSA Forms and HHS Forms have also been provided.

For information on Minimum Data Set (MDS) manuals and forms, click here.

For OASIS information, click here.

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CMS Forms
Form #TitleRevision DateContact
CMS 18F APPLICATION FOR HOSPITAL INSURANCE (ENGLISH & SPANISH) 06/91 SOCIAL SECURITY
CMS 29
(449 KB)
REQUEST TO ESTABLISH ELIGIBILITY TO PARTICIPATE IN HI FOR AGED/DISABLED TO PROVIDE RURAL HEALTH CLINIC SERVICES 05/78 STATE AGENCY
CMS 30
(473 KB)
RURAL HEALTH CLINIC SURVEY REPORT 05/78 STATE AGENCY
HCFA 30E CRUCIAL DATA EXTRACT 05/85 STATE AGENCY
CMS 36
English
(419 KB),
Spanish
(3 KB)
CONSENT FOR HOME VISIT 12/90 STATE AGENCY
CMS 36P
English
(419 KB)Spanish
(49 KB)
CONSENT FOR HOME VISIT FOR PACE SERVICES EVALUATION 07/02 STATE AGENCY
CMS 40B APPLICATION FOR ENROLLMENT IN MEDICARE 01/90 SOCIAL SECURITY
CMS 40F APPLICATION FOR ENROLLMENT IN MEDICAL INS UNDER MEDICARE 11/81 SOCIAL SECURITY
CMS 43 APPLICATION FOR HEALTH INSURANCE UNDER MEDICARE FOR INDIVIDUAL WITH CHRONIC RENAL DISEASE 08/81 SOCIAL SECURITY
CMS 116
(33 KB)
CLINICAL LAB IMPROVEMENT AMENDMENTS (CLIA) APPLICATION FOR CERTIFICATION 06/02 STATE AGENCY
CMS-R-131-G (127 KB) ADVANCE BENEFICIARY NOTICE (ABN) (GENERAL USE) 06/02 Beneficiary Notices Initiative (BNI) Website
CMS-R-131-L (135 KB) ADVANCE BENEFICIARY NOTICE (ABN) (LABORATORY TESTS) 06/02 Beneficiary Notices Initiative (BNI) Website
CMS 179
(656 KB)
TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL 07/92 STATE AGENCY
CMS-R-193 IMPORTANT MESSAGE FROM MEDICARE (IM) 01/03 Beneficiary Notices Initiative (BNI) Website
CMS 209
(441 KB)
LABORATORY PERSONNEL REPORT (CLIA) 09/92 STATE AGENCY
CMS 216
(147 KB)
ORGAN PROCUREMENT ORGANIZATION - HISTO-COMPATIBILITY LAB STATEMENT OF REIMBURSABLE COSTS 03/95 RIVERBEND GOVERNMENT BENEFIT ADMINISTRATORS (BC/BS OF TENNESSEE)
(423) 755-5950
CMS 222
(40 KB)
INDEPENDENT RURAL HEALTH CLINIC WORKSHEET 10/96 INTERMEDIARY
CMS 265
(42 KB)
INDEPENDENT RENAL DIALYSIS FACILITY COST REPORT 08/95 INTERMEDIARY
CMS 282
(480 KB)
BLOOD BANK INSPECTION CHECKLIST & REPORT 10/92 STATE AGENCY
HCFA 287
(104 KB)
HOME OFFICE COST STATEMENT 11/95 INTERMEDIARY
CMS-R-296 (142 KB) HOME HEALTH ADVANCE BENEFICIARY NOTICE (1 PAGE) 06/02 Beneficiary Notices Initiative (BNI) Website
HCFA 339 MEDICARE PROVIDER COST REPORT REIMBURSEMENT QUESTIONNAIRE 11/95 INTERMEDIARY, CARRIER
CMS 352
(415 KB)
PART A RECONSIDERATION INPUT RECORD 06/86 INTERMEDIARY
CMS 353
(4 KB)
PART A PREHEARING INPUT RECORD 06/86 INTERMEDIARY
CMS 359
(428 KB)
CORF REPORT FOR CERTIFICATION TO PARTICIPATE IN MEDICARE 07/03 STATE AGENCY
CMS 360
(557 KB)
CORF SURVEY REPORT 09/03 STATE AGENCY
CMS 370
(6 KB)
HEALTH INSURANCE BENEFITS AGREEMENT-ABULATORY SURGICAL CENTER 04/02 STATE AGENCY
CMS 377
(62 KB)
AMBULATORY SURGICAL CENTER REQUEST FOR CERTIFICATION IN MEDICARE 01/97 STATE AGENCY
CMS 378
(427 KB)
AMBULATORY SURGICAL CENTER SURVEY REPORT 01/97 STATE AGENCY
HCFA 378E AMBULATORY SURGICAL CTR REPORT--CRUCIAL DATA EXTRACT STATE AGENCY
CMS 379
(16 KB)
FINANCIAL STATEMENT OF DEBTOR 01/83
CMS 381
(421 KB)
MODEL LETTER REQUESTING IDENTIFICATION OF EXTENSION UNITS 09/83 STATE AGENCY
CMS 382
(10 KB)
ESRD BENEFICIARY SELECTION 08/97 INTERMEDIARY
CMS 383
(9 KB)
HEALTH INSURANCE CASE SUMMARY 12/82 INTERMEDIARY
CMS 384
(11 KB)
QIO CASE SUMMARY 03/92
CMS 416
(399KB)
ANNUAL EPSDT PARTICIPATION REPORT 06/99 STATE AGENCY
CMS 417
(10 KB)
HOSPICE REQUEST FOR CERTIFICATION IN MEDICARE 04/84 STATE AGENCY
CMS 437
(442 KB)
PSYCHIATRIC UNIT CRITERIA WORKSHEET 04/90 STATE AGENCY
CMS 437A
(464 KB)
REHAB UNIT CRITERIA WORKSHEET 02/03 STATE AGENCY
CMS 437B
(435 KB)
REHAB HOSPITAL CRITERIA WORKSHEET 02/03 STATE AGENCY
CMS L457 ACKNOWLEDGMENT OF REQUEST FOR MEDICARE MEDICAL INSURANCE TERMINATION 02/03 SOCIAL SECURITY
CMS L458 ACKNOWLEDGMENT OF REQUEST FOR PREMIUM HOSPITAL INSURANCE TERMINATION 02/03 SOCIAL SECURITY
CMS 460
(90 KB)

INSTRUCTIONS (70 KB)
MEDICARE PARTICIPATING PHYSICIAN OR SUPPLIER AGREEMENT 10/02 CARRIER
CMS 462A/B
(47 KB)
CLIA ADVERSE ACTION EXTRACT 05/97 STATE AGENCY
CMS 462L
(58 KB)
ADVERSE ACTION EXTRACT FOR SNFs & NFs 07/95 STATE AGENCY
CMS 484
(44 KB)
CERTIFICATE OF MEDICAL NECESSITY - Oxygen DMERC 484.2 11/99 DMERC
CMS-500
(English)
(410 KB)

CMS-500
(Spanish)
(414 KB)
NOTICE OF MEDICARE PREMIUM PAYMENT DUE 01/03 SOCIAL SECURITY
CMS 562
(9 KB)
MEDICARE/MEDICAID/CLIA COMPLAINT FORM 01/93 STATE AGENCY
CMS L564 MEDICARE INFORMATION 04/00 SOCIAL SECURITY
CMS 566 MEDICARE MANAGED CARE DISENROLLMENT 06/97 SOCIAL SECURITY
CMS576
(344 KB)
ORGAN PROCUREMENT REQUEST FOR DESIGNATION AS AN OPO 01/93 STATE AGENCY
CMS576A
(331 KB)
HEALTH INSURANCE BENEFITS AGREEMENT WITH ORGAN PROCUREMENT ORGANIZATION 01/93 STATE AGENCY
CMS 588
(451 KB)
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER (EFT) 09/03 INTERMEDIARY, CARRIER
CMS 632 FOI (12 KB) FREEDOM OF INFORMATION ACT REQUEST 09/00 INTERMEDIARY, CARRIER
CMS 633
(7 KB)
INVOICE OF FEES FOR FOIA SERVICES 02/93 INTERMEDIARY, CARRIER
CMS 636
(6 KB)
TRANSMITTAL NOTICE HEARING CASE 06/88 INTERMEDIARY
CMS 643
(24 KB)
HOSPICE SURVEY & DEFICIENCIES REPORT 11/94 STATE AGENCY
CMS 667
(453 KB)
ALTERNATE QUALITY ASSESSMENT SURVEY (CLIA) 07/00 STATE AGENCY
CMS 668B
(448 KB)
POST LAB SURVEY-CLIA 07/00 STATE AGENCY
CMS 671
(367 KB)
LTC FACILITY APPLICATION FOR MEDICARE/MEDICAID 12/02 STATE AGENCY
CMS 672
(363 KB)
RESIDENT CENSUS AND CONDITIONS OF RESIDENTS 10/98 STATE AGENCY
CMS 673
(17 KB)
EXTENDED/PARTIAL EXTENDED SURVEY WORKSHEET 07/95 STATE AGENCY
CMS 677
(332 KB)
MEDICATION PASS WORKSHEET 07/95 STATE AGENCY
CMS 700
(11 KB)
PLAN OF TREATMENT FOR OUTPATIENT REHAB 11/91 STATE AGENCY
CMS 701
(12 KB)
UPDATED PLAN OF PROGRESS FOR OUTPATIENT REHAB 11/91 STATE AGENCY
CMS 724
(50 KB)
MEDICARE/MEDICAID PSYCHIATRIC HOSPITAL SURVEY DATA 09/94 STATE AGENCY
CMS 725
(29 KB)
SURVEYOR WORKSHEET FOR PSYCHIATRIC HOSPITAL REVIEW: TWO SPECIAL CONDITIONS 09/94 STATE AGENCY
CMS 726
(421 KB)
CMS DEATH RECORD REVIEW DATA SHEET 09/94 STATE AGENCY
CMS 727
(35 KB)
CMS NURSING COMPLEMENT DATA 09/94 STATE AGENCY
CMS 728
(37 KB)
CMS STAFF DATA 09/94 STATE AGENCY
CMS 729
(35 KB)
DATA COLLECTION MEDICAL STAFF COVERAGE 09/94 STATE AGENCY
CMS 801
(331 KB)
OFFSITE SURVEY PREP WORKSHEET 07/95 STATE AGENCY
CMS 802
(428 KB)
ROSTER/SAMPLE MATRIX 07/99 STATE AGENCY
CMS 802P
(420 KB)
PROVIDER INSTRUCTIONS FOR HCFA 802 12/99 STATE AGENCY
CMS 802S
(423 KB)
SURVEYOR INSTRUCTIONS FOR HCFA 802 07/99 STATE AGENCY
CMS 803
(11 KB)
GENERAL OBSERVATIONS OF FACILITY 07/95 STATE AGENCY
CMS 804
(425 KB)
KITCHEN/FOOD SERVICE OBSERVATION 07/95 STATE AGENCY
CMS 805
(16 KB)
RESIDENT REVIEW WORKSHEET 07/95 STATE AGENCY
CMS 806
RESIDENT - A (352 KB),
GROUP - B
(350 KB)
,
FAMILY - C (426 KB)
QUALITY OF LIFE ASSESSMENT 07/95 STATE AGENCY
CMS 807
(6 KB)
SURVEYOR NOTES WORKSHEET 07/95 STATE AGENCY
CMS 820
(43 KB)
IN-CENTER HEMODIALYSIS (HD) CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2004 12/03 ESRD NETWORK
CMS 821
(47 KB)
PERITONEAL DIALYSIS CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2004 01/04 ESRD NETWORK
CMS 838
(36 KB)
MEDICARE CREDIT BALANCE REPORTING REQUIREMENTS 10/03 INTERMEDIARY
CMS 841
(47 KB)
CERTIFICATE OF MEDICAL NECESSITY - Hospital Beds - DMERC 01.02A 04/96 DMERC
CMS 842
(41 KB)
CERTIFICATE OF MEDICAL NECESSITY - Support Surfaces - DMERC 01.02B 04/96 DMERC
CMS 843
(68 KB)
CERTIFICATE OF MEDICAL NECESSITY - Motorized Wheelchairs - DMERC 02.03A 05/97 DMERC
CMS 844
(59 KB)
Certificate of Medical Necessity - Manual Wheelchairs, DMERC 02.03B 05/97 DMERC
CMS 846
(50 KB)
CERTIFICATE OF MEDICAL NECESSITY - Lymphedema Pumps - DMERC 04.03B 05/97 DMERC
CMS 847
(56 KB)
CERTIFICATE OF MEDICAL NECESSITY - Osteogenesis Stimulators - DMERC 04.03C 05/97 DMERC
CMS 848
(62 KB)
CERTIFICATE OF MEDICAL NECESSITY - Transcutaneous Electrical Serve Stimulator (TENS) - DMERC 06.02B 04/96 DMERC
CMS 849
(53 KB)
CERTIFICATE OF MEDICAL NECESSITY - Seat Lift Mechanism - DMERC 07.02A 04/96 DMERC
CMS 850
(44 KB)
CERTIFICATE OF MEDICAL NECESSITY - Power Operated Vehicle (POV) - DMERC 07.02B 04/96 DMERC
CMS 851
(63 KB)
CERTIFICATE OF MEDICAL NECESSITY - External Infusion Pump - DMERC 09.02 04/96 DMERC
CMS 852
(60 KB)
CERTIFICATE OF MEDICAL NECESSITY - Parenteral Nutrition - DMERC 10.02A 04/96 DMERC
CMS 853
(64 KB)
CERTIFICATE OF MEDICAL NECESSITY - Enteral Nutrition - DMERC 10.02B 04/96 DMERC
CMS 854
(24 KB)
CERTIFICATE OF MEDICAL NECESSITY - Section C Continuation Form - DMERC 11.01 05/97 DMERC
CMS 855A
(4 KB)
APPLICATION FOR HEALTH CARE PROVIDERS THAT WILL BILL MEDICARE FISCAL INTERMEDIARIES 11/01 INTERMEDIARY
CMS 855B
(1 MB)
APPLICATION FOR HEALTH CARE SUPPLIERS THAT WILL BILL MEDICARE CARRIERS 11/01 CARRIER
CMS 855I
(799 KB)
APPLICATION FOR INDIVIDUAL HEALTH CARE PRACTITIONERS 11/01 CARRIER
CMS 855R
(316 KB)
APPLICATION FOR INDIVIDUAL HEALTH CARE PRACTITIONERS TO REASSIGN MEDICARE BENEFITS 11/01 CARRIER
CMS 855S
(913 KB)
APPLICATION FOR DMEPOS SUPPLIERS 11/01 NATIONAL SUPPLIER CLEARING HOUSE
(803) 754-3951
HCFA 1450
(9 KB)
UB-92 MEDICARE UNIFORM INSTITUTIONAL PROVIDER BILL STANDARD REGISTER - SEE LOCAL YELLOW PAGES
CMS 1490S

(14 KB)
& SPANISH
(443 KB)
PATIENT'S REQUEST FOR MEDICAL PAYMENT 2/87 CARRIER,
SOCIAL SECURITY
CMS 1490U
(13KB)
REQUEST FOR MEDICARE PAYMENT BY ORGANIZATIONS 01/01 CARRIER
CMS 1491
(33 KB)
REQUEST FOR MEDICARE PAYMENT, AMBULANCE 01/89 CARRIER
CMS 1500
(67 KB)
HEALTH INSURANCE CLAIM FORM 12/90 CARRIER, GOVERNMENT PRINTING OFFICE
(202)512-1800 or LOCAL MAJOR PRINTER
CMS 1513
(444 KB)
DISCLOSURE OF OWNERSHIP & CONTROL INTEREST STATEMENT 05/86 STATE AGENCY
CMS 1515A (400 KB) HOME HEALTH FUNCTIONAL ASSESSMENT INSTRUMENT: MODULE A 06/90 STATE AGENCY
CMS 1515B
(432 KB)
HOME HEALTH FUNCTIONAL ASSESSMENT INSTRUMENT: MODULE B 06/90 STATE AGENCY
CMS 1515C (413 KB) HOME HEALTH FUNCTIONAL ASSESSMENT MODULE C: HOME VISIT 06/90 STATE AGENCY
CMS 1515D (418 KB) HOME HEALTH FUNCTIONAL ASSESSMENT PATIENT CARE: MODULE D 06/90 STATE AGENCY
CMS 1515E
(421 KB)
HOME HEALTH FUNCTION & CARE SUMMARY: MODULE E 06/90 STATE AGENCY
CMS 1515F
(405 KB)
CALENDAR WORKSHEET - PRESCRIBED VISITS 06/90 STATE AGENCY
CMS 1537
(121 KB)
MEDICARE/MEDICAID HOSPITAL SURVEYOR'S WORKSHEET 11/03 STATE AGENCY
CMS 1537C (433 KB) HOSPITAL SURVEY REPORT 01/92 STATE AGENCY
CMS 1539
(426 KB)
MEDICARE/MEDICAID CERTIFICATION & TRANSMITTAL 07/84 STATE AGENCY
CMS 1541A
(6 KB)
RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN EMERGENCY CASES 04/95 STATE AGENCY
CMS 1541B
(417 KB)
RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN EMERGENCY CASES INVESTIGATION REPORT 04/95 STATE AGENCY
CMS 1557
(444 KB)
SURVEY REPORT FORM - CLIA 09/92 STATE AGENCY
CMS 1561
(424 KB)
HEALTH INSURANCE BENEFIT AGREEMENT 07/01 STATE AGENCY
CMS 1561A (432 KB) HEALTH INSURANCE BENEFIT AGREEMENT - RURAL HEALTH CLINIC 04/02 STATE AGENCY
CMS 1563
(6 KB)
MONTHLY INTERMEDIARY REPORT ON MEDICARE SECONDARY PAYER SAVINGS 11/97 INTERMEDIARY
CMS 1564
(3 KB)
MONTHLY CARRIER REPORT ON MEDICARE SECONDARY PAYER SAVINGS 11/97 CARRIER
CMS 1572A
(49 KB)
HHA SURVEY & DEFICIENCIES REPORT 08/90 STATE AGENCY
CMS 1592 SMI PREMIUM ACCTG FORM 07/86 SOCIAL SECURITY
CMS 1666
(424 KB)
REGIONAL OFFICE REQUEST FOR ADDITIONAL INFORMATION 04/80 STATE AGENCY
CMS 1696
(10 KB)
APPOINTMENT OF REPRESENTATIVE 10/84 INTERMEDIARY, CARRIER,
SOCIAL SECURITY
CMS 1728
(7 KB)
HOME HEALTH AGENCY COST REPORT 04/01 INTERMEDIARY
CMS 1763 REQ FOR TERMINATION OF PREMIUM HI/SMI 05/97 SOCIAL SECURITY
CMS 1771
(12 KB)
ATTENDING PHYSICIANS STATEMENT AND DOCUMENTATION FOR MEDICARE EMERGENCY 09/77 SOCIAL SECURITY, INTERMEDIARY
CMS 1856
(445 KB)
REQUEST TO ESTABLISH ELIGIBILITY IN MEDICARE AND/OR MEDICAID PROGRAM 10/80 STATE AGENCY
CMS 1880
(448 KB)
REQUEST FOR CERTIFICATION AS SUPPLIER OF PORTABLE XRAY SERVICES 10/80 STATE AGENCY
CMS 1882
(59 KB)
PORTABLE XRAY SURVEY REPORT 03/98 STATE AGENCY
CMS 1893
(77 KB)
OUTPATIENT PHYSICAL THERAPY - SPEECH PATHOLOGY SURVEY REPORT 10/99 STATE AGENCY
CMS 1938
(12 KB)
SSO REQUEST FOR CARRIER/INTERMEDIARY ASSISTANCE 01/88 SOCIAL SECURITY
CMS 1957 SSO REPORT OF STATE BUY IN PROBLEM 03/94 SOCIAL SECURITY
CMS 1960 REQUEST FOR EVIDENCE OF MEDICAL NECESSITY 05/69 SOCIAL SECURITY
CMS 1964
(414 KB)
REQUEST FOR REVIEW OF PART B MEDICARE CLAIM 09/91 INTERMEDIARY, CARRIER,
SOCIAL SECURITY
CMS 1965
(33 KB)
REQUEST FOR HEARING - PART B MEDICARE CLAIM 05/03 INTERMEDIARY, CARRIER,
SOCIAL SECURITY
CMS 1980
(15 KB)
CARRIER OR INTERMEDIARY REQUEST FOR SSO ASSISTANCE 03/78 INTERMEDIARY, CARRIER,
SOCIAL SECURITY
CMS 1984
(7 KB)
HOSPICE COST REPORT 4/99 INTERMEDIARY
CMS 2007
(420 KB)
PROVIDER TIE-IN NOTICE 03/82 INTERMEDIARY, CARRIER
STATE AGENCY
CMS 2088-92
(7 KB)
OUTPATIENT REHAB PROVIDER COST REPORT 12/02 INTERMEDIARY, CARRIER
CMS 2178 HI/SMI ENTITLEMENT PROBLEM REFERRAL 06/00 SOCIAL SECURITY
CMS 2384 THIRD PARTY PREMIUM BILLING REQUEST, MEDICARE 03/87 SOCIAL SECURITY
CMS 2501 RECONSIDERATION DETERMINATION 01/72 INTERMEDIARY,
CMS 2540-96
(7 KB)
SNF & SNF HEALTH CARE COMPLEX COST REPORT 02/03 INTERMEDIARY
HCFA 2540S-97
(7 KB)
SNF & SNF HEALTH CARE COMPLEX COST REPORT 10/99 INTERMEDIARY
CMS 2552-96
(7 KB)
COST REPORT FOR ELECTRONIC FILING OF HOSPITALS 08/02 INTERMEDIARY
CMS 2567
(7 KB)
STATEMENT OF DEFICIENCIES & PLAN OF CORRECTION 02/99 CMS RO,
STATE AGENCY
CMS 2567B
(38 KB)
POST-CERTIFICATION REVISIT REPORT 09/92 STATE AGENCY
HCFA 2589 HI MAGNETIC TAPE LABEL 08/79 CARRIER
CMS 2649
(412 KB)
REQUEST FOR RECONSIDERATION PART A HI BENEFITS 11/03 INTERMEDIARY, CARRIER,
SOCIAL SECURITY
CMS 2690 REQ FOR CANCELLATION OF SMI 03/78 SOCIAL SECURITY
CMS 2728
(14 KB)
ESRD MEDICAL EVIDENCE REPORT MEDICARE ENTITLEMENT AND/OR PATIENT REGISTRATION 06/97 SOCIAL SECURITY
CMS 2744
(14 KB)
ESRD FACILITY SURVEY 11/88 ESRD NETWORK
CMS 2746
(90 KB)
ESRD DEATH NOTIFICATION 10/04 ESRD NETWORK
CMS 2786M
(415 KB)
FIRE SAFETY SURVEY - RATING RESIDENTS - 2000 CODE 03/04 STATE AGENCY
CMS 2786R
(447 KB)
FIRE SAFETY SURVEY REPORT 2000 CODE - HEALTH CARE - MEDICARE - MEDICAID 03/04 STATE AGENCY
CMS 2786S
(76 KB)
FIRE SAFEY SURVEY REPORT SHORT FORM - MEDICARE-MEDICAID 03/04 STATE AGENCY
CMS 2786T
(431 KB)
FIRE/SMOKE ZONE EVALUATION WORKSHEET FOR HEALTH CARE FACILITIES - 2000 CODE 03/04 STATE AGENCY
CMS 2786U
(442 KB)
FIRE SAFETY SURVEY REPORT - AMBULATORY SURGICAL CENTERS - MEDICARE- 2000 CODE 03/04 STATE AGENCY
CMS 2786V
(492 KB)
FIRE SAFETY SURVEY REPORT ICF/MR - SMALL FACILITIES - 2000 CODE 03/04 STATE AGENCY
CMS 2786W
(472 KB)
FIRE SAFETY SURVEY REPORT - ICF/MR - LARGE FACILITIES - 2000 CODE 03/04 STATE AGENCY
CMS 2786X
(477 KB)
FIRE SAFETY SURVEY REPORT - ICF/MR APARTMENT HOUSE - 2000 CODE 03/04 STATE AGENCY
CMS 2786Y
(442 KB)
FIRE SAFETY REPORT ICF/MR - SMALL FSES - 2000 CODE 03/04 STATE AGENCY
CMS 2802
(22 KB)
REQUEST FOR VALIDATION OF ACCREDITATION 12/01 STATE AGENCY
CMS 2802A REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR LAB 01/02 CMS RO
CMS 2802B
(427 KB)
REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR HOSPICE 01/02 STATE AGENCY
CMS 2802C (428 KB) REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR HOME HEALTH AGENCY 01/02 STATE AGENCY
CMS 2802D (427 KB) REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR AMBULATORY SURGICAL CENTER 01/02 STATE AGENCY
CMS 2802E (429 KB) REQUEST FOR VALIDATION OF ACCREDITATION FOR CRITICAL ACCESS HOSPITAL SURVEY 10/03 STATE AGENCY
CMS 2878
(18 KB)
ACCREDITED HOSPITAL ALLEGATIONS REPORT 04/86 STATE AGENCY
CMS 3070G
(54 KB)
ICF/MR SURVEY REPORT 03/01 STATE AGENCY
CMS 3070H
(37 KB)
ICF/MR DEFICIENCIES REPORT 11/00 STATE AGENCY
CMS 3070I
(429 KB)
INDIVIDUAL OBSERVATION WORKSHEET 10/95 STATE AGENCY
CMS 3427
(70 KB)
ESRD APPLICATION/NOTIFICATION AND SURVEY/CERTIFICATION REPORT 06/97 STATE AGENCY
CMS 3509
(401 KB)
ALJ MEDICARE CASE FOLDER (CMS) 08/02 INTERMEDIARY, CARRIER
CMS 3516
(652 KB)
NOTICE OF MEDICARE PREMIUM PAYMENT DUE 10/84 SOCIAL SECURITY
CMS 4040 REQUEST FOR ENROLLMENT IN SUPPLEMENTARY MEDICAL INSURANCE (ENGLISH & SPANISH) 08/91 SOCIAL SECURITY
CMS 5011A
English
(416 KB)
, Spanish
(416 KB)
REQUEST FOR PART A MEDICARE HEARING BY ALJ (ENGLISH & SPANISH) 06/91 INTERMEDIARY,
CMS 5011B
English
(420 KB)
, Spanish
(420 KB)
REQUEST FOR PART B MEDICARE HEARING BY ALJ (ENGLISH & SPANISH) 06/91 CARRIER,
SOCIAL SECURITY
CMS-10003-NDMC
(103 KB)
NOTICE OF DENIAL OF MEDICAL COVERAGE 06/01 Beneficiary Notices Initiative (BNI) Website
CMS-10003-NDP
(93 KB)
NOTICE OF DENIAL OF PAYMENT 06/01 Beneficiary Notices Initiative (BNI) Website
CMS 10055 SKILLED NURSING FACILITY ADVANCED BENEFICIARY NOTICE Beneficiary Notices Initiative (BNI) Website
CMS 10092 A-K HOSPITAL ADVANCED BENEFICIARY NOTICES 10/03 Beneficiary Notices Initiative (BNI) Website
CMS 10095 A-B NOTICE & EXPLANATION OF MEDICARE NON-COVERAGE 12/03 Medicare Managed Care Appeals and Grievances
CMS 10111 NOTICE OF EXCLUSIONS FROM MEDICARE BENEFITS - HOME HEALTH AGENCY (NEMB-HHA) Beneficiary Notices Initiative (BNI) Website
CMS 10113
English
(414 KB)
,
Spanish
(123KB)
MEDICARE REPLACEMENT DRUG DEMONSTRATION INSTRUCTIONS & FORMS 08/04 TrailBlazer Health Enterprises, LLC
1-866-563-5386
TTY 1-886-563-5387
CMS 20007 NOTICE OF EXCLUSIONS FROM MEDICARE BENEFITS (NEMB) 01/03 Beneficiary Notices Initiative (BNI) Website
CMS 20014 NOTICE OF EXCLUSIONS FROM MEDICARE BENEFITS - SKILLED NURSING FACILITY (NEMB-SNF) Beneficiary Notices Initiative (BNI) Website
CMS 20016A
English
(233 KB)
,
Spanish
(153KB)
STANDARD ENROLLMENT FORM FOR A MEDICARE-APPROVED DRUG DISCOUNT CARD 07/04 SHIP Program
CMS 20016B
English
(249 KB)
,
Spanish
(159KB)
STANDARD ENROLLMENT FORM FOR A MEDICARE-APPROVED DRUG DISCOUNT CARD AND A CREDIT TO HELP PAY FOR YOUR PRESCRIPTION DRUGS 07/04 SHIP Program
CMS 20016E
English
(387 KB)
,
Spanish
(87 KB)
MEDICARE-APPROVED DRUG DISCOUNT CARD INSTRUCTION SHEET FOR COMPLETING FORMS CMS 20016-A AND CMS 20016-B 07/04 SHIP Program
CMS 20017
(8 KB)
ADVISORY PANEL ON AMBULATORY PAYMENT 05/04 APC Website
CMS 20024
(68 KB)
CMS EVALUATION FORM - AS PART OF THE APPLICATION FOR THE INCREASE IN A HOSPITAL'S FTE CAP(S) UNDER SECTION 422 OF THE MEDICARE MODERNIZATION ACT OF 2003 08/04 Acute Inpatient Website

NOTE: Although CMS forms may be photocopied, please refer to Section 1140 of the Social Security Act (42 U.S.C. 1320b-10, paragraphs (a)(2)(B)) regarding restrictions on sale of CMS materials.

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Last Modified on Friday, October 08, 2004