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Administrative Simplification Compliance Act Waiver Request Form Advance Beneficiary Notice (ABN) (CMS R-131-G) Appointment of Representative Form (CMS-1696) Clerical Error/Omission Reopening Request Form Clerical Error/Omission Reopening Request Form EDI Enrollment Form EDI Provider Recertification EDI Registration for Existing Submitters (Illinois, Indiana, Kentucky, Ohio Providers) EDI Registration for New Submitters (Illinois, Indiana, Kentucky, Ohio Providers)  Electronic Remittance Advice (ERA) Online Request Electronic Remittance Advice Request (Illinois, Indiana, Kentucky, Ohio Providers) Electronic Remittance Advice Request for only (Massachusetts, Maine, New Hampshire, and Vermont Providers) External Report Redirection Request FISS/Direct Data Entry Request (Indiana, Kentucky, Ohio Providers) FISS/Direct Data Entry (DDE) request (California, Illinois, Wisconsin) FISS/Direct Data Entry Request (MI and VA) FISS/Direct Data Entry Request (Massachusetts, Maine, New Hampshire, and Vermont Providers) FISS/Direct Data Entry (DDE) Request (NY, CT) Hospice PIP Rate Review Form Interim Rate Review Documentation Request Form for Critical Access Hospitals Interim Rate Review Documentation Request Form for Hospitals Interim Rate Review Documentation Request Form for PIP Hospitals Interim Rate Review Documentation Request Form for TEFRA Hospital/Unit Medicare Correspondence Request Form Medicare Credit Balance Report (CMS-838) Excel Spreadsheet Medicare Credit Balance Report Form and Instructions (CMS-838) Medicare Hearing by an Administrative Law Judge Request Form (CMS-20034) Medicare Monthly Review Hard Copy Subscription Form Medicare Part A Letter of Authorization for only MA, ME, NH, VT Medicare Part A Letter of Authorization (Massachusetts, Maine, New Hampshire, and Vermont Providers) Medicare Part A PS&R Electronic Report Request Form Medicare Redetermination Request Form (CMS-20027) Outbound Report Request (Illinois, Indiana, Kentucky, Ohio Providers) PC-ACE Pro32—Institutional Application (Illinois, Indiana, Kentucky, Ohio Providers)  PC-ACE Pro32 - Institutional application PC-ACE Pro32 Order form PC Print Order form Provider Request for Legacy PS&R Form Provider SmartTransfer Enrollment form PS & R Extract Order Form PS&R Outbound Report Request Form (Massachusetts, Maine, New Hampshire, and Vermont Providers) Remittance Advice Request Form Submitter Action Request Provider Authorization Form  Page last modified: 10/8/2008

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