Forms

Appeals

• Appointment of Representative Form (CMS-1696)         
• Clerical Error/Omission Reopening Request Form       
• Medicare Reconsideration Request Form (CMS-20033)         
• Medicare Redetermination Request Form (CMS-20027)         
• Request for Medicare Hearing by an Administrative Law Judge (CMS-20034)         

Audit & Reimbursement

• CMS Hospital Cost Report Forms and Instructions         
• Certification for No Medicare Utilization       
• Cost Report Submission Checklist        (233 KB)
• 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 TEFRA Hospital/Unit       
• Provider Request for PS&R Form       
• Request for Waiver of Electronic Filing of Medicare Cost Report       

Coverage

• Advance Beneficiary Notice of Noncoverage (CMS-R-131)          
• Fee-for-Service Expedited Determination Notices         
• Therapy Preapproval Form        (576 KB)

Customer Care

• 1-800-MEDICARE Authorization to Disclose Personal Health Information         
• Customer Care Online Inquiry Form
• Medicare Correspondence Request Form       
• Remittance Advice Request Form       

Documentation

• Cover Sheet for Electronically Submitted Medical Records       
• Dual-Chamber Cardiac Pacemaker NCD-Based Checklist       
• Medicare Part A PWK Fax/Mail Cover Sheet        (757 KB)

Electronic Data Interchange

• 5010 Trading Partner Testing/Transition Plan         
• Administrative Simplification Compliance Act Waiver Request Form       
• EDI E-mail Inquiry Form
• EDI Enrollment Agreement Form
• EDI Submitter Action Request Form
• EDI Submitter Change of Address and/or Contact Information Form       
• EDI Third-Party Authorization Form
• Medicare Part A Intermediary Outbound Report Request Form: IL, IN, KY, and OH       
• Part A Logon Request Form (FISS/Direct Data Entry)

Enrollment

• CMS-588 Electronic Funds Transfer (EFT) Authorization Agreement         
• CMS-855A Medicare Enrollment Application - Institutional Providers         

Other

• CMS Forms Index         
• Medicare Monthly Review Hard-Copy Subscription Form       

Repayments

• Applying For an Extended Repayment Plan (CT, NY)       
• Applying For an Extended Repayment Plan (FQHC)       
• Applying For an Extended Repayment Plan (IL)       
• Applying For an Extended Repayment Plan (WI)       
• Immediate Recoupment Request Form – Electronic/E-mail
• Immediate Recoupment Request Form       
• Medicare Credit Balance Report (CMS-838) Excel Spreadsheet        (482 KB)
• Medicare Credit Balance Report Form and Instructions (CMS-838)        (2 MB)
• Overpayment Recovery Unit Part A Voluntary Refund Form