CMS Forms List
The following provides access and/or information for many CMS forms. You may also use the "Search" feature to more quickly locate information for a specific form number or form title.
Showing 1-172 of 172 entries
| Form # | Form Title | Revision Date |
|---|---|---|
| CMS 10003-NDMCP | NOTICE OF DENIAL OF MEDICAL COVERAGE/PAYMENT ("INTEGRATED DENIAL NOTICE") | 2013-06-01 |
| CMS 10036 | Inpatient Rehabilitation Facility-Patient Assessment Instrument | 2006-01-01 |
| CMS 10055 | SKILLED NURSING FACILITY ADVANCED BENEFICIARY NOTICE | |
| CMS 10069 | Medicare Waiver Demonstration Application | 2013-12-31 |
| CMS 10095DENC | Detailed Explanation of Non-Coverage | 2006-12-01 |
| CMS 10095NOMNC | NOTICE OF MEDICARE NON-COVERAGE | 2006-12-01 |
| CMS 10106 PDF | 1-800-Medicare Authorization to Disclosure Personal Health Information | 2019-03-01 |
| CMS 10114 | NATIONAL PROVIDER IDENTIFIER (NPI) APPLICATION/UPDATE FORM | 2021-08-01 |
| CMS 10123 | EXPEDITED REVIEW NOTICE-NOTICE OF MEDICARE PROVIDER NON-COVERAGE | 2008-02-29 |
| CMS 10124 | EXPEDITED REVIEW NOTICE-DETAILED EXPLANATION OF NON-COVERAGE | 2008-02-29 |
| CMS 10125 | DME Information Form - External Infusion Pumps DME 09.03 | 2017-02-01 |
| CMS 10126 | DME Information Form - Enteral and Parenteral Nutrition DME 10.03 | 2017-02-01 |
| CMS 10146 | Notice of Denial of Medicare Prescription Drug Coverage English/Spanish | 2019-01-01 |
| CMS 10156 | Retiree Drug Subsidy | 2005-08-01 |
| CMS 10164 | Centers for Medicare and Medicaid Services EDI Registration Form; and EDI Enrollment Form | 2019-03-25 |
| CMS 10175 | Electronic File Interchange Organization (EFIO) Certification Statement | 2022-02-28 |
| CMS 10198 | Creditable Coverage Disclosure to CMS On-line Form and Instructions | 2017-12-27 |
| CMS 10221 | Independent Diagnostic Testing Facilities-Site Investigation | 2020-05-01 |
| CMS 10252 | DATA USE AGREEMENT (DUA) CERTFICATE OF DISPOSITION (COD) FOR DATA ACQUIRED FROM THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) | 2012-05-29 |
| CMS 10269 | CMN Positive Airway Pressure (PAP)Devices for Obstructive Sleep Apnea | 2009-12-01 |
| CMS 10287 | Medicare Quality of Care Complaint Form | 2015-11-01 |
| CMS 116 | CLINICAL LABORATORY IMPROVEMENT AMENDMENTS OF 1988 (CLIA) APPLICATION FOR CERTIFICATION | 2020-04-01 |
| CMS 1450 | UB-04 Uniform Bill | 2007-03-01 |
| CMS 1490S | PATIENT'S REQUEST FOR MEDICAL PAYMENT (English/Spanish) | 2021-06-01 |
| CMS 1500 | Health Insurance Claim Form | 2012-02-01 |
| CMS 1515A-OBSOLETE | HHA Functional Assessment Instrumental | 2013-05-01 |
| CMS 1539 | MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL | 1984-07-01 |
| CMS 1541B | RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN EMERGENCY CASES INVESTIGATION REPORT | 2014-09-01 |
| CMS 1557 | SURVEY REPORT FORM - CLIA | 2021-02-01 |
| CMS 1561 | HEALTH INSURANCE BENEFIT AGREEMENT | 2001-07-01 |
| CMS 1561A | HEALTH INSURANCE BENEFIT AGREEMENT-RURAL HEALTH CLINIC | 2002-04-01 |
| CMS 1563 | Monthly Intermediary Report on Medicare Secondary Payer Savings | 1997-11-01 |
| CMS 1564 | MONTHLY CARRIER REPORT ON MEDICARE SECONDARY PAYER SAVINGS | 1997-11-01 |
| CMS 1572 | HHA SURVEY REPORT | 2022-07-01 |
| CMS 1592 | SMI PREMIUM ACCTG FORM | 1986-07-01 |
| CMS 1666 | REGIONAL OFFICE REQUEST FOR ADDITIONAL INFORMATION | 1980-04-01 |
| CMS 1696 | APPOINTMENT OF REPRESENTATIVE | 2021-09-01 |
| CMS 1728 | HOME HEALTH AGENCY COST REPORT | 2001-06-01 |
| CMS 1763 | Request for Termination of Premium Hospital Insurance of Supplementary Medical Insurance | 2017-12-01 |
| CMS 1771 | ATTENDING PHYSICIANS STATEMENT AND DOCUMENTATION FOR MEDICARE EMERGENCY | 1977-09-01 |
| CMS 179 | TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL | 1992-07-01 |
| CMS 1856 | Request for Certification in the Medicare and/or Medicaid Program to Provide Outpatient Physical Therapy and/or Speech Pathology Services | 2006-12-11 |
| CMS 1880 | REQUEST FOR CERTIFICATION AS SUPPLIER OF PORTABLE XRAY SERVICES | 2018-05-31 |
| CMS 1882 | PORTABLE XRAY SURVEY REPORT | 2009-02-01 |
| CMS 18F | APPLICATION FOR HOSPITAL INSURANCE (English / Spanish) | 1991-02-01 |
| CMS 1957 | SSO REPORT OF STATE BUY IN PROBLEM | 2018-04-01 |
| CMS 1960 | REQUEST FOR EVIDENCE OF MEDICAL NECESSITY | 1969-05-01 |
| CMS 1980 | CARRIER OR INTERMEDIARY REQUEST FOR SSO ASSISTANCE | 1978-03-01 |
| CMS 1984 | HOSPICE COST REPORT | 2005-02-01 |
| CMS 20014 | NOTICE OF EXCLUSIONS FROM MEDICARE BENEFITS - SKILLED NURSING FACILITY (NEMB-SNF) | |
| CMS 20017 | ADVISORY PANEL ON HOSPITAL OUTPATIENT PAYMENT | 2017-04-01 |
| CMS 20027 | MEDICARE REDETERMINATION REQUEST FORM | 0019-07-01 |
| CMS 20031 | TRANSFER (ASSIGNMENT) OF APPEAL RIGHTS | 2018-03-01 |
| CMS 20033 | MEDICARE RECONSIDERATION REQUEST FORM | 0019-07-01 |
| CMS 20034A/B | REQUEST FOR MEDICARE HEARING BY AN ADMINISTRATIVE LAW JUDGE | 2015-03-01 |
| CMS 20037 | APPLICATION FOR ACCESS TO CMS COMPUTER SYSTEMS | 2010-06-01 |
| CMS 20040 | Regional Office Meeting/Speaker Request Form | 0005-12-01 |
| CMS 20041 | Speech Invitation Request Background Information | 0005-12-01 |
| CMS 20056 | Medicare Adminstration Observation | 2013-02-01 |
| CMS 2007 | PROVIDER TIE IN NOTICE | 1982-03-01 |
| CMS 20134 | Medicare Enrollment Application - Medicare Diabetes Prevention Program (MDPP) Suppliers | 2018-01-01 |
| CMS 20143 | Medicare Easy Pay Premium Statement | 2021-11-01 |
| CMS 2088-92 | OUTPATIENT REHAB PROVIDER COST REPORT | 2004-12-01 |
| CMS 209 | LABORATORY PERSONNEL REPORT (CLIA) | 2021-01-01 |
| CMS 216 | ORGAN PROCUREMENT ORGANIZATION-HISTO-COMPATIBILITY LAB STATEMENT OF REIMBURSABLE COSTS | 2005-11-01 |
| CMS 2178 | HI/SMI ENTITLEMENT PROBLEM REFERRAL | 2006-09-01 |
| CMS 222 | INDEPENDENT RURAL HEALTH CLINIC WORKSHEET | 2005-01-01 |
| CMS 2384 | THIRD PARTY PREMIUM BILLING REQUEST, MEDICARE | 2018-03-01 |
| CMS 2540-96 | SNF AND SNF HEALTH CARE COMPLEX COST REPORT | 2006-05-01 |
| CMS 2552-96 | COST REPORT FOR ELECTRONIC FILING OF HOSPITALS | 2004-05-01 |
| CMS 2567 | STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | 1999-02-01 |
| CMS 2567B | POST-CERTIFICATION REVISIT REPORT | 1992-09-01 |
| CMS 265 | INDEPENDENT RENAL DIALYSIS FACILITY COST REPORT | 2005-03-01 |
| CMS 2690 | REQ FOR CANCELLATION OF SMI | 1978-03-01 |
| CMS 2728 | ESRD MEDICAL EVIDENCE REPORT MEDICARE ENTITLEMENT AND/OR PATIENT REGISTRATION | 2006-03-01 |
| CMS 2744A | ESRD FACILITY SURVEY (DIALYSIS UNIT ONLY) | 2020-07-01 |
| CMS 2744B | END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM ESRD FACILITY SURVEY (TRANSPLANT CENTERS ONLY) | 2020-07-01 |
| CMS 2746 | ESRD DEATH NOTIFICATION | 2006-08-01 |
| CMS 2786M | Worksheet for Determining Evacuation Capability - ICF-IID (Existing Facilities Only) 2012 Life Safety Code | 2018-07-01 |
| CMS 2786R | Fire Safety Survey Report - Health Care 2012 Life Safety Code | 2018-07-01 |
| CMS 2786T | Fire Safety Evaluation System - Health Care 2012 Life Safety Code | 2018-07-01 |
| CMS 2786U | Fire Safety Survey Report - ASC & ESRD 2012 Life Safety Code | 2018-07-01 |
| CMS 2786V | Fire Safety Survey Report - ICF-IID (Small Facilities) 2012 Life Safety Code | 2018-07-01 |
| CMS 2786W | Fire Safety Survey Report - ICF-IID (Large Facilities) 2012 Life Safety Code | 2018-07-01 |
| CMS 2786X | Fire Safety Survey Report - ICF-IID (Apartment House) 2012 Life Safety Code | 2018-07-01 |
| CMS 2786Y | Fire Safety Evaluation System - ICF-IID (Small Facilities) 2012 Life Safety Code | 2018-07-01 |
| CMS 2802 | REQUEST FOR VALIDATION OF ACCREDITATION | 2011-02-01 |
| CMS 2802B | REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR HOSPICE | 2011-02-01 |
| CMS 2802C | REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR HOME HEALTH AGENCY | 2019-03-31 |
| CMS 2802D | REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR AMBULATORY SURGICAL CENTER | 2011-02-01 |
| CMS 2802E | REQUEST FOR VALIDATION OF ACCREDITATION FOR CRITICAL ACCESS HOSPITAL SURVEY | 2011-02-01 |
| CMS 2802F | Authorization for State Agency Psychiatric Hospital Validation Survey | 2011-11-01 |
| CMS 287 | HOME OFFICE COST STATEMENT | 1995-11-01 |
| CMS 2878 | ACCREDITED HOSPITAL ALLEGATIONS REPORT | 1986-04-01 |
| CMS 29 | VERIFICATION OF CLINIC DATA ? RURAL HEALTH CLINIC PROGRAM | 2022-06-01 |
| CMS 3070G | ICF/IID Survey Report | 2013-03-01 |
| CMS 3070H | ICF/IID Deficiencies Report | 2013-03-01 |
| CMS 3070I | INDIVIDUAL OBSERVATION WORKSHEET | 1995-10-01 |
| CMS 339 | PROVIDER COST REPORT REIMBURSEMENT QUESTIONNAIRE | 2006-04-30 |
| CMS 3509 | ALJ MEDICARE CASE FOLDER (CMS) | 2002-08-02 |
| CMS 359 | CORF REPORT FOR CERTIFICATION TO PARTICIPATE IN MEDICARE | 2021-04-01 |
| CMS 36 | CONSENT FOR HOME VISIT (English/Spanish) | 1990-12-01 |
| CMS 360 | COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY SURVEY REPORT | 2021-03-31 |
| CMS 36P | CONSENT FOR HOME VISIT FOR PACE SERVICES EVALUATION | 2002-07-01 |
| CMS 370 | HEALTH INSURANCE BENEFITS AGREEMENT-AMBULATORY SURGICAL CENTER | 2002-04-01 |
| CMS 377 | AMBULATORY SURGICAL CENTER REQUEST FOR CERTIFICATION IN MEDICARE | 0021-02-28 |
| CMS 379 | FINANCIAL STATEMENT OF DEBTOR | 2007-07-01 |
| CMS 381 | MODEL LETTER REQUESTING IDENTIFICATION OF EXTENSION LOCATIONS | 2005-12-01 |
| CMS 383 | HEALTH INSURANCE CASE SUMMARY | 1982-12-01 |
| CMS 384 | QIO CASE SUMMARY | 1992-03-01 |
| CMS 4040 | REQUEST FOR ENROLLMENT IN SUPPLEMENTARY MEDICAL INSURANCE (English / Spanish) | 2020-08-01 |
| CMS 40B | Application for Enrollment in Medicare - Part B (Medical Insurance) | 2021-07-31 |
| CMS 416 | Early ad Periodic Screening Diagnostic and Treatment Participation Report | 1999-06-01 |
| CMS 417 | HOSPICE REQUEST FOR CERTIFICATION IN MEDICARE | 2010-08-01 |
| CMS 43 | APPLICATION FOR HOSPITAL INSURANCE BENEFITS FOR INDIVIDUALS WITH END STAGE RENAL DISEASE | 2018-04-01 |
| CMS 437 | PSYCHIATRIC UNIT CRITERIA WORKSHEET | 2006-04-01 |
| CMS 437A | REHAB UNIT CRITERIA WORKSHEET | 2015-07-28 |
| CMS 437B | REHAB HOSPITAL CRITERIA WORKSHEET | 2015-07-28 |
| CMS 460 | MEDICARE PARTICIPATING PHYSICIAN OR SUPPLIER AGREEMENT | 2019-04-01 |
| CMS 462L | ADVERSE ACTI0N EXTRACT FOR SNFs AND NFs | 1995-07-01 |
| CMS 484 | CERTIFICATE OF MEDICAL NECESSITY - Oxygen DME 484.5 | 2017-02-01 |
| CMS 500 | MEDICARE PREMIUM BILL | 2021-11-01 |
| CMS 5011A-B | REQUEST FOR MEDICARE HEARING BY ADMINISTRATIVE LAW JUDGE | 2017-01-01 |
| CMS 576 | Organ Procurement Request for Designation as an OPO | 1993-01-01 |
| CMS 576A | Health Insurance Benefits Agreement with Organ Procurement Organization | 2006-06-30 |
| CMS 588 | Electronic Funds Transfer (EFT) Authorization Agreement | 2020-12-01 |
| CMS 632FOI | FREEDOM OF INFORMATION ACT REQUEST | 2013-03-01 |
| CMS 633 | Invoice of Fees for FOIA Services | 2008-01-01 |
| CMS 643 (28 KB) | Hospice Survey AND Deficiencies Report | 2008-06-01 |
| CMS 671 | LTC Facility Application for Medicare/Medicaid | 2018-09-01 |
| CMS 672 | Resident Census and Conditions of Residents | 2012-05-01 |
| CMS 724 | Medicare/Medicaid Psychiatric Hospital Survey Data | 1994-09-01 |
| CMS 725 | Surveyor Worksheet for Psychiatric Hospital Review:Two Special Conditions | 1994-09-01 |
| CMS 726 | CMS Death Record Review Data Sheet | 1994-09-01 |
| CMS 727 | CMS Nursing Complement Data | 1994-09-01 |
| CMS 728 | CMS Staff Data | 1994-09-01 |
| CMS 729 | Data Collection Medical Staff Coverage | 1994-09-01 |
| CMS 801 | Offsite Survey Prep Worksheet | 1995-07-01 |
| CMS 802 | Roster/Sample Matrix | 2018-01-01 |
| CMS 807 | Surveyor Notes Worksheet | 1995-07-01 |
| CMS 820 | IN-CENTER HEMODIALYSIS (HD) CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2005 | 2005-01-01 |
| CMS 821 | PERITONEAL DIALYSIS CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2005 | 2005-01-01 |
| CMS 838 | Medicare Credit Balance Reporting Requirements | 2003-10-01 |
| CMS 846 | Certificate of Medical Necessity - Pneumatic Compression Devices DME 04.04B | 2017-02-01 |
| CMS 847 | Certificate of Medical Necessity - Osteogenesis Stimulators - DME 04.04C | 2017-02-01 |
| CMS 848 | Certificate of Medical Necessity - Transcutaneous Electrical Nerve Stimulator (TENS) - DME 06.03B | 2017-02-01 |
| CMS 849 | Certificate of Medical Necessity - Seat Lift Mechanisms - DME 07.03A | 2017-02-01 |
| CMS 854 | Certificate of Medical Necessity - DME 11.02 | 2017-02-02 |
| CMS 855A | Medicare Enrollment Application - Institutional Providers | 2011-07-01 |
| CMS 855B | Medicare Enrollment Application - Clinics/Group Practices and Certain Other Suppliers | 2021-03-01 |
| CMS 855I | Medicare Enrollment Application - Physicians and Non-Physician Practitioners | 2018-12-01 |
| CMS 855O | Medicare Enrollment Application - Registration For Eligible Ordering and Referring Physicians and Non-Physician Practitioners | 2017-01-01 |
| CMS 855R | Medicare Enrollment Application - Reassignment of Medicare Benefits | 2020-01-01 |
| CMS 855S | Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers | 2016-05-01 |
| CMS L457 | ACKNOWLEDGMENT OF REQUEST FOR MEDICARE MEDICAL INSURANCE TERMINATION | 2003-02-01 |
| CMS L458 | ACKNOWLEDGMENT OF REQUEST FOR PREMIUM HOSPITAL INSURANCE TERMINATION | 2003-02-01 |
| CMS L564 | REQUEST FOR EMPLOYMENT INFORMATION | 2020-05-26 |
| CMS R-0235 (66 KB) | Data Use Agreement (DUA) (Agreement for use of Centers for Medicare and Medicaid Services (CMS) data containing individual-specific information | 2020-06-11 |
| CMS R-0235A (35 KB) | Addendum to Data Use Agreement (DUA) | 2020-06-11 |
| CMS R-0235L (64 KB) | Data Use Agreement (DUA)- Limited Data Sets | 2020-06-11 |
| CMS R-0235M | Medicaid Agency Data Use Agreement | 2007-07-01 |
| CMS R-0235MA | Addendum to the Medicaid State Agency Data Use Agreement | 2006-03-01 |
| CMS R-0235MC | Compliance Plan for Accounting for Disclosures of Privacy Protected Data Released From a System of Records (SOR) Housed in a State-Located Server | 2006-03-01 |
| CMS R-0235U (48 KB) | Data Use Agreement (DUA)- Update to Existing DUA | 2020-06-11 |
| CMS R-131 | ADVANCE BENEFICIARY NOTICE (ABN) | 2011-03-01 |
| CMS R-193 | IMPORTANT MESSAGE FROM MEDICARE (IM) | 2010-07-01 |
| CMS R-285 | Request for Retirement Benefit Information | 2018-04-01 |
| CMS R-296 | HOME HEALTH ADVANCE BENEFICIARY NOTICE | 2009-08-01 |
| CMS-10396 | Medication Therapy Management Program Standardize Format | 2012-01-20 |
| CMS-10455 | Report of a Hospital Death Associated with Restraint or Seclusion | 2018-07-19 |
| CMS-R-0235 D1 | DSH Data Use Agreement for Cost Reporting Periods Prior to those that include December 8, 2004 | 2009-12-01 |
| CMS-R-0235 D2 | DSH Data Use Agreement for Cost Reporting Periods that Include December 8, 2004 and therafter | 2009-12-01 |
Page Last Modified:
12/01/2021 07:02 PM