Forms

Appeals

• Appointment of Representative Form (CMS-1696)         
• Medicare Part B Appeals Request Form       
• Medicare Reconsideration Request Form (CMS-20033)         
• Request for Medicare Hearing by an Administrative Law Judge (CMS-20034)         
• Transfer of Appeal Rights       

Coverage

• Advance Beneficiary Notice of Noncoverage (CMS-R-131)          
• 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       

Documentation

• Cover Sheet for Electronically Submitted Medical Records       
• Dual-Chamber Cardiac Pacemaker NCD-Based Checklist       
• Evaluation & Management Documentation Training Tool        (375 KB)
• Medicare Part B PWK Fax/Mail Cover Sheet        (827 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

Enrollment

• CMS-588 Electronic Funds Transfer (EFT) Authorization Agreement         
• CMS-855B Medicare Enrollment Application - Clinics/Group Practices and Certain Other Suppliers         
• CMS-855I Medicare Enrollment Application - Physicians and Non-Physician Practitioners         
• CMS-855O Medicare Enrollment Application - For Eligible Ordering and Referring Physicians and Non-Physician Practitioners         
• CMS-855R Medicare Enrollment Application - Reassignment of Medicare Benefits         
• Medicare Opt-Out Affidavit       
• Medicare Participating Physician or Supplier Agreement Form (CMS-460)         
• Medicare Private Contract Form       
• Provider Enrollment Verification of Practice Address Location       

Other

• CMS Forms Index         
• Medicare Monthly Review Hard-Copy Subscription Form       
• Medicare Physician Fee Schedule/Enrollment Package Request Form       

Overpayments

• Extended Repayment Plan Request Form       
• Immediate Recoupment Request Form – Electronic/E-mail
• Immediate Recoupment Request Form        (275 KB)
• Medicare Part B Overpayment Request Form       
• Medicare Secondary Payer Overpayment Request Form       
• Medicare Secondary Payer Part B Carrier Voluntary Refund Form       
• Overpayment Recovery Unit Part B Carrier Voluntary Refund Form