CMS Forms List

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101.255c-9.335-9.379-9.317-24.544.04-33.901l22.667-22.667c9.373-9.373 24.569-9.373 33.941 0L285.475 239.03c9.373 9.372 9.373 24.568.001 33.941z"></path> </svg> </span> <span class="ds-c-usa-banner__button-icon-container" hidden=""> <svg aria-hidden="true" class="ds-c-icon ds-c-icon--close ds-c-icon--close-thin ds-c-usa-banner__button-icon" viewbox="-2 -2 18 18" xmlns="http://www.w3.org/2000/svg"> <path fill="none" stroke="currentColor" stroke-linecap="round" stroke-width="2" d="M0 13.0332964L13.0332964 0M13.0332964 13.0332964L0 0"></path> </svg> </span> </button> </header> <div class="ds-c-usa-banner__guidance ds-u-leading--base ds-u-font-size--base"> <div id="usa-banner--17__panel" class="ds-c-usa-banner__guidance-container" hidden=""> <div class="ds-c-usa-banner__guidance-item"> <svg aria-hidden="true" class="ds-c-icon ds-c-icon--building-circle ds-c-usa-banner__guidance-icon" viewbox="0 0 54 54" xmlns="http://www.w3.org/2000/svg"> <g> <path 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Share sensitive information only on official, secure websites.</p> </div> </div> </div> </div> </div> </div> </section> <div class="ds-l-container cms-tracker--header-top"> <div class="ds-l-row"> <div class="header-top-wrapper ds-l-md-col--12"> <button id="js-navbar-toggle" class="navbar-toggle navbar-toggle-primary-menu ds-u-lg-display--none" aria-expanded="false" aria-label="Open Main" aria-haspopup="true"> <i class="fal fa-bars" focusable="false"></i> </button> <div class="region region-cms-header-primary"> <div id="block-cms-evo-sitebranding" class="block block-system block-system-branding-block"> <div class="site-logo"> <a href="/" rel="home"> <img src="/themes/custom/cms_evo/logo.svg" alt="CMS.gov" /> </a> </div> <div class="ds-u-lg-display--block ds-u-display--none site-slogan"> Centers for Medicare & Medicaid Services </div> <div class="newsroom-branding"> <h2 class="ds-u-lg-font-size--xl ds-u-color--white ds-u-margin--0 ds-u-font-weight--semibold"> <a 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</li> <li class="menu-item menu-item--l2 menu-item--expanded"> <span class="menu-item-element" aria-current="false">Regulations & guidance</span> <div class="subnav-wrapper--2 ds-u-display--none"> <div class="subnav-header"> <span class="back-to-l2 ds-u-lg-display--none">Back to <span class="l2-placeholder"></span> menu</span> <h3 class="subnav-title-h3" style="position:relative;text-align:left;">section title h3</h3> </div> <div class="menu-wrapper"> <ul class="menu"> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/regulations-guidance/manuals" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/172771">Manuals</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/regulations-guidance/transmittals" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/172701">Transmittals</a> </li> <li class="menu-item menu-item--l3"> <a href="/medicare/regulations-guidance/guidance" 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href="/medicare/regulations-guidance/office-attorney-advisor" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/172636">Office of the Attorney Advisor (OAA)</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/regulations-guidance/provider-reimbursement-review-board" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/172576">Provider Reimbursement Review Board (PRRB)</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/regulations-guidance/geographic-classification-review-board" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/172611">Medicare Geographic Classification Review Board (MGCRB)</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/regulations-guidance/physician-self-referral" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/170671">Physician 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menu-item--l3 menu-item--collapsed"> <a href="/medicare/coding-billing/place-of-service-codes" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/171996">Place of service codes</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/coding-billing/icd-10-codes" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/171421">ICD-10 codes</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/coding-billing/healthcare-common-procedure-system" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/171561">Healthcare Common Procedure Coding System (HCPCS)</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/coding-billing/outpatient-code-editor" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/171341">Integrated Outpatient Code Editor</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/coding-billing/ncci-medicare" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/1617246">National Correct Coding Initiative (NCCI) edits</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/coding-billing/ncci-medicaid" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/1617251">NCCI for Medicaid</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/coding-billing/electronic-billing" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/170371">Electronic billing</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/coding-billing/medicare-administrative-contractors-macs" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/177546">Medicare Administrative Contractors (MACs)</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/coding-billing/provider-customer-service-program" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/176031">Provider Customer Service Program</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/coding-billing/skilled-nursing-facility-snf-consolidated-billing" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/170676">Skilled Nursing Facility (SNF) consolidated billing</a> </li> <li class="menu-item menu-item--l3"> <a href="/roster-billing" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/1612841">Roster billing</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/coding-billing/therapy-services" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/170641">Therapy services</a> </li> <li class="menu-item menu-item--l3"> <a href="/medicare/coding-billing/claims-public-health-emergencies" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/1620676">Medicare claims & public health emergencies</a> </li> <li class="menu-item menu-item--l3"> <a href="/medicare/coding-billing/guide-medical-technology-companies-other-interested-parties" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/1899941">Guide for Medical Technology Companies and Other Interested Parties</a> </li> </ul> </div> </div> </li> <li class="menu-item menu-item--l2 menu-item--expanded"> <span class="menu-item-element" aria-current="false">Payment</span> <div class="subnav-wrapper--2 ds-u-display--none"> <div class="subnav-header"> <span class="back-to-l2 ds-u-lg-display--none">Back to <span class="l2-placeholder"></span> menu</span> <h3 class="subnav-title-h3" style="position:relative;text-align:left;">section title h3</h3> </div> <div class="menu-wrapper"> <ul class="menu"> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/payment/fee-for-service-providers/part-b-drugs/average-drug-sales-price" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/170451">Medicare Part B Drug Average Sales Price</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/payment/fee-for-service-providers" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/193361">All Fee-For-Service-Providers</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/payment/fee-schedules" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/170661">Fee schedules</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/payment/prospective-payment-systems" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/170741">Prospective Payment Systems</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/payment/opioid-treatment-program" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/1289826">Opioid Treatment Programs (OTP)</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/covidvax-provider" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/1483486">Covid-19 Vaccine Toolkit</a> </li> <li class="menu-item menu-item--l3"> <a href="/medicare/payment/bankruptcy" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/185906">Bankruptcy</a> </li> <li class="menu-item menu-item--l3"> <a href="/medicare/payment/sustainable-growth-rates-conversion-factors" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/169931">Sustainable Growth Rates & Conversion Factors</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/payment/medicare-advantage-rates-statistics" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/169841">Medicare Advantage Rates & Statistics</a> </li> </ul> </div> </div> </li> <li class="menu-item menu-item--l2 menu-item--expanded"> <span class="menu-item-element" aria-current="false">Medicare-Medicaid coordination</span> <div class="subnav-wrapper--2 ds-u-display--none"> <div class="subnav-header"> <span class="back-to-l2 ds-u-lg-display--none">Back to <span class="l2-placeholder"></span> menu</span> <h3 class="subnav-title-h3" style="position:relative;text-align:left;">section title h3</h3> </div> <div class="menu-wrapper"> <ul class="menu"> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/medicaid-coordination/about" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/174821">Medicare-Medicaid Coordination Office</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/medicaid-coordination/center-program-integrity/resources" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/674936">Resources</a> </li> <li class="menu-item menu-item--l3"> <a href="/medicare/medicaid-coordination/about/qualified-medicare-beneficiary-program" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/184631">Qualified Medicare beneficiary program</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/medicaid-coordination/center-program-integrity/spotlight" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/674941">Spotlight</a> </li> <li class="menu-item menu-item--l3"> <a href="/medicare/medicaid-coordination/center-program-integrity/events" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/674946">Events</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicaid-chip/medicare-coordination/financial-alignment" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/178246">Financial alignment initiative</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicaid-chip/medicare-coordination/avoidable-hospitalizations" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/181236">Initiative to reduce avoidable hospitalizations </a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/medicaid-coordination/center-program-integrity/reports-guidance" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/674951">Reports & Guidance</a> </li> <li class="menu-item menu-item--l3"> <a href="/medicare/medicaid-coordination/pace" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/175651">Program of All-Inclusive Care for the Elderly (PACE)</a> </li> <li class="menu-item menu-item--l3"> <a href="/medicare/medicaid-coordination/center-program-integrity/reporting-fraud" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/674956">Reporting Fraud</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/medicaid-coordination/plans" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/178296">Resources for Medicare-Medicaid plans</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/medicaid-coordination/states" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/1355341">Resources for state Medicaid agencies</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/medicaid-coordination/healthcare-fraud-prevention-partnership" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/1313131">Healthcare Fraud Prevention Partnership</a> </li> <li class="menu-item menu-item--l3"> <a href="/about-cms/information-systems/clinical-templates" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/189991">Clinical Templates</a> </li> </ul> </div> </div> </li> <li class="menu-item menu-item--l2 menu-item--expanded"> <span class="menu-item-element" aria-current="false">Appeals & grievances</span> <div class="subnav-wrapper--2 ds-u-display--none"> <div class="subnav-header"> <span class="back-to-l2 ds-u-lg-display--none">Back to <span class="l2-placeholder"></span> menu</span> <h3 class="subnav-title-h3" style="position:relative;text-align:left;">section title h3</h3> </div> <div class="menu-wrapper"> <ul class="menu"> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/appeals-grievances/fee-for-service" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/171221">Original Medicare appeals</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/appeals-grievances/managed-care" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/169961">Managed Care appeals & grievances</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/appeals-grievances/prescription-drug" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/171101">Medicare Prescription drug appeals & grievances</a> </li> <li class="menu-item menu-item--l3"> <a href="/medicare/appeals-grievances/ombudsman-center" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/193386">Ombudsman Center</a> </li> <li class="menu-item menu-item--l3"> <a href="/medicare/appeals-grievances/appeals-decision-search-part-c-d" class="menu-item-element" aria-current="false" data-drupal-link-system-path="qic-decision-search">Appeals Decision Search (Part C & Part D)</a> </li> </ul> </div> </div> </li> <li class="menu-item menu-item--l2 menu-item--expanded"> <span class="menu-item-element" aria-current="false">Quality</span> <div class="subnav-wrapper--2 ds-u-display--none"> <div class="subnav-header"> <span class="back-to-l2 ds-u-lg-display--none">Back to <span class="l2-placeholder"></span> menu</span> <h3 class="subnav-title-h3" style="position:relative;text-align:left;">section title h3</h3> </div> <div class="menu-wrapper"> <ul class="menu"> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/quality/value-based-programs" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/188566">Value-based programs</a> </li> <li class="menu-item menu-item--l3"> <a href="/medicare/quality/initiatives/hospital-quality-initiative/person-family-engagement" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/182996">Person & Family Engagement</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/quality/quality-improvement-organizations" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/169871">Quality improvement organizations</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/quality/nursing-home-improvement" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/171236">Nursing home quality improvement</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/quality/inpatient-rehabilitation-facility" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/175616">Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP)</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/quality/home-health" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/170541">Home Health Quality Reporting Program</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/quality/end-stage-renal-disease-esrd-quality-incentive-program" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/176126">ESRD Quality Incentive Program</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/quality/meaningful-measures-initiative/cms-quality-strategy" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/178276">CMS National Quality Strategy</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/quality/hospice" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/175556">Hospice Quality Reporting Program</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/quality/long-term-care-hospital" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/175511">Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP)</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/quality/appropriate-use-criteria-program" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/180421">Appropriate Use Criteria Program</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/quality/measures" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/172001">Quality measures</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/quality/clinical-laboratory-improvement-amendments" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/172651">Clinical Laboratory Improvement Amendments (CLIA)</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/advantage-quality-improvement-program" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/177561">Medicare Advantage quality improvement program</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/quality/physician-compare-initiative" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/175221">Physician compare initiative</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/quality/initiatives" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/169636">Quality initiatives</a> </li> <li class="menu-item menu-item--l3"> <a href="/medicare/health-drug-plans/part-c-d-performance-data" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/171491">Part C and D Performance Data</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/quality/snf-quality-reporting-program" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/180061"> Skilled Nursing Facility (SNF) Quality Reporting Program (QRP)</a> </li> </ul> </div> </div> </li> <li class="menu-item menu-item--l2 menu-item--expanded"> <span class="menu-item-element" aria-current="false">Health & safety standards</span> <div class="subnav-wrapper--2 ds-u-display--none"> <div class="subnav-header"> <span class="back-to-l2 ds-u-lg-display--none">Back to <span class="l2-placeholder"></span> menu</span> <h3 class="subnav-title-h3" style="position:relative;text-align:left;">section title h3</h3> </div> <div class="menu-wrapper"> <ul class="menu"> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/health-safety-standards/quality-safety-oversight-general-information" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/169631">Quality, safety & oversight - General information</a> </li> <li class="menu-item menu-item--l3"> <a href="/medicare/health-safety-standards/accreditation-programs" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/171481">Accreditation programs</a> </li> <li class="menu-item menu-item--l3"> <a href="/medicare/health-safety-standards/civil-monetary-penalties" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/182431">Civil monetary penalties</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/health-safety-standards/quality-safety-oversight-emergency-preparedness" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/172346">Quality, safety & oversight - Emergency preparedness</a> </li> <li class="menu-item menu-item--l3"> <a href="/medicare/health-safety-standards/state-survey-agencies" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/171271">State survey agencies</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/health-safety-standards/certification-compliance" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/171241">Certification & compliance</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/health-safety-standards/enforcement" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/169811">Enforcement</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/health-safety-standards/guidance-for-laws-regulations" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/170071">Quality, safety & oversight - Guidance for laws & regulations</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/health-safety-standards/promising-practices-project" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/172211">Promising practices project</a> </li> <li class="menu-item menu-item--l3"> <a href="/medicare/health-safety-standards/education-division" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/173371">Quality, safety & oversight - Education division (QSED)</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/health-safety-standards/conditions-coverage-participation" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/172616">Conditions for coverage & participation</a> </li> </ul> </div> </div> </li> <li class="menu-item menu-item--l2 menu-item--expanded"> <span class="menu-item-element" aria-current="false">Employers & plan sponsors</span> <div class="subnav-wrapper--2 ds-u-display--none"> <div class="subnav-header"> <span class="back-to-l2 ds-u-lg-display--none">Back to <span class="l2-placeholder"></span> menu</span> <h3 class="subnav-title-h3" style="position:relative;text-align:left;">section title h3</h3> </div> <div class="menu-wrapper"> <ul class="menu"> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/employers-plan-sponsors/creditable-coverage" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/171701">Creditable coverage</a> </li> </ul> </div> </div> </li> <li class="menu-item menu-item--l2"> <span class="menu-item-element" aria-current="false">IC-Placeholder-1</span> </li> <li class="menu-item menu-item--l2 menu-item--expanded"> <span class="menu-item-element" aria-current="false">Audits & Compliance</span> <div class="subnav-wrapper--2 ds-u-display--none"> <div class="subnav-header"> <span class="back-to-l2 ds-u-lg-display--none">Back to <span class="l2-placeholder"></span> menu</span> <h3 class="subnav-title-h3" style="position:relative;text-align:left;">section title h3</h3> </div> <div class="menu-wrapper"> <ul class="menu"> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/audits-compliance/part-a-cost-report" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/185256">Part A cost report audit</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/audits-compliance/part-c-d" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/175921">Part C/Part D compliance & audits</a> </li> </ul> </div> </div> </li> <li class="menu-item menu-item--l2 menu-item--expanded menu-item--active-trail"> <span class="menu-item-element" aria-current="false">Forms & notices</span> <div class="subnav-wrapper--2 ds-u-display--none"> <div class="subnav-header"> <span class="back-to-l2 ds-u-lg-display--none">Back to <span class="l2-placeholder"></span> menu</span> <h3 class="subnav-title-h3" style="position:relative;text-align:left;">section title h3</h3> </div> <div class="menu-wrapper"> <ul class="menu"> <li class="menu-item menu-item--l3"> <a href="/medicare/forms-notices/cms-forms" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/170166">CMS forms</a> </li> <li class="menu-item menu-item--l3 menu-item--active-trail"> <a href="/medicare/forms-notices/cms-forms-list" class="menu-item-element active-page is-active" aria-current="page" data-drupal-link-system-path="node/174306">CMS forms list</a> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/forms-notices/beneficiary-notices-initiative" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/170686">Beneficiary Notices Initiative (BNI)</a> </li> </ul> </div> </div> </li> <li class="menu-item menu-item--l2 menu-item--expanded"> <span class="menu-item-element" aria-current="false">Health & drug plans</span> <div class="subnav-wrapper--2 ds-u-display--none"> <div class="subnav-header"> <span class="back-to-l2 ds-u-lg-display--none">Back to <span class="l2-placeholder"></span> menu</span> <h3 class="subnav-title-h3" style="position:relative;text-align:left;">section title h3</h3> </div> <div class="menu-wrapper"> <ul class="menu"> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/health-drug-plans/plan-payment" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/171981">Plan payment</a> </li> <li class="menu-item menu-item--l3"> <a href="/medicare/health-drug-plans/plan-payment-data" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/175081">Plan payment data</a> </li> <li class="menu-item menu-item--l3"> <a href="/medicare/health-drug-plans/medical-loss-ratio" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/180161">Medical loss ratio</a> </li> <li class="menu-item menu-item--l3"> <a href="/medicare/health-drug-plans/coverage-gap-discount-program" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/175906">Coverage Gap Discount Program</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/health-drug-plans/managed-care-marketing" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/170611">Managed care marketing</a> </li> <li class="menu-item menu-item--l3"> <a href="/medicare/health-drug-plans/medicare-advantage-application" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/170651">Medicare Advantage application</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/health-drug-plans/medigap" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/170466">Medigap (Medicare supplement health insurance)</a> </li> <li class="menu-item menu-item--l3"> <a href="/medicare/health-drug-plans/medical-savings-account" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/172066">Medical Savings Account (MSA)</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/health-drug-plans/private-fee-for-service-plans" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/170301">Private Fee-for-Service Plans</a> </li> <li class="menu-item menu-item--l3"> <a href="/medicare/enrollment-renewal/health-plans/prepayment" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/170521">Health Care Prepayment Plans (HCPPs)</a> </li> <li class="menu-item menu-item--l3"> <a href="/medicare/enrollment-renewal/health-plans/cost" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/170656">Cost plans</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/enrollment-renewal/special-needs-plans" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/171676">Special needs plans</a> </li> <li class="menu-item menu-item--l3"> <a href="/medicare/health-drug-plans/network-adequacy" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/171301">Network adequacy</a> </li> </ul> </div> </div> </li> <li class="menu-item menu-item--l2 menu-item--expanded"> <span class="menu-item-element" aria-current="false">Coordination of benefits & recovery</span> <div class="subnav-wrapper--2 ds-u-display--none"> <div class="subnav-header"> <span class="back-to-l2 ds-u-lg-display--none">Back to <span class="l2-placeholder"></span> menu</span> <h3 class="subnav-title-h3" style="position:relative;text-align:left;">section title h3</h3> </div> <div class="menu-wrapper"> <ul class="menu"> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/coordination-benefits-recovery/overview" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/177001">Overview</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/coordination-benefits-recovery/mandatory-insurer-reporting-group-health-plans" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/176856">Mandatory Insurer Reporting for Group Health Plans (GHP)</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/coordination-benefits-recovery/mandatory-insurer-reporting" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/176951">Mandatory insurer reporting (NGHP)</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/coordination-benefits-recovery/workers-comp-set-aside-arrangements" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/176641">Workers' comp Medicare set aside arrangements</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/coordination-benefits-recovery/attorney-services" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/177026">Attorney services</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/coordination-benefits-recovery/beneficiary-services" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/177036">Beneficiary services</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/coordination-benefits-recovery/coba-trading-partners" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/176761">COBA Trading Partners</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/coordination-benefits-recovery/employer-services" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/170361">Employer services</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/coordination-benefits-recovery/insurer-services" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/170846">Insurer services</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/coordination-benefits-recovery/prescription-drug-assistance-programs" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/176791">Prescription drug assistance programs</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicare/coordination-benefits-recovery/provider-services" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/170406">Provider services</a> </li> </ul> </div> </div> </li> <li class="menu-item menu-item--l2 menu-item--expanded"> <span class="menu-item-element" aria-current="false">Settlements</span> <div class="subnav-wrapper--2 ds-u-display--none"> <div class="subnav-header"> <span class="back-to-l2 ds-u-lg-display--none">Back to <span class="l2-placeholder"></span> menu</span> <h3 class="subnav-title-h3" style="position:relative;text-align:left;">section title h3</h3> </div> <div class="menu-wrapper"> <ul class="menu"> <li class="menu-item menu-item--l3"> <a href="/medicare/settlements/jimmo" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/193381">Jimmo Settlement</a> </li> <li class="menu-item menu-item--l3"> <a href="/medicare/settlements/ryan" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/193486">Ryan Settlement</a> </li> </ul> </div> </div> </li> </ul> </div> </li> <li class="menu-item menu-item--l1 menu-item--expanded"> <span class="menu-item-element" aria-current="false">Medicaid/CHIP</span> <div class="subnav-wrapper--1 ds-u-display--none"> <div class="subnav-header"> <span class="back-to-main ds-u-lg-display--none">Back to main menu</span> <h2 class="subnav-title-h2" style="position:relative;text-align:left;width:auto;height:auto;">section title h2</h2> </div> <ul class="menu"> <li class="menu-item menu-item--l2 menu-item--expanded"> <span class="menu-item-element" aria-current="false">What is Medicaid?</span> <div class="subnav-wrapper--2 ds-u-display--none"> <div class="subnav-header"> <span class="back-to-l2 ds-u-lg-display--none">Back to <span class="l2-placeholder"></span> menu</span> <h3 class="subnav-title-h3" style="position:relative;text-align:left;">section title h3</h3> </div> <div class="menu-wrapper"> <ul class="menu"> <li class="menu-item menu-item--l3"> <a href="https://www.medicaid.gov" class="menu-item-element" aria-current="false">Visit Medicaid.gov</a> </li> <li class="menu-item menu-item--l3"> <a href="https://www.medicaid.gov/about-us/beneficiary-resources/index.html#statemenu" class="menu-item-element" aria-current="false">View Medicaid maps</a> </li> <li class="menu-item menu-item--l3"> <a href="http://www.medicaid.gov/chip/index.html" class="menu-item-element" aria-current="false">Visit CHIP.gov</a> </li> </ul> </div> </div> </li> <li class="menu-item menu-item--l2 menu-item--expanded"> <span class="menu-item-element" aria-current="false">Medicare-Medicaid Coordination</span> <div class="subnav-wrapper--2 ds-u-display--none"> <div class="subnav-header"> <span class="back-to-l2 ds-u-lg-display--none">Back to <span class="l2-placeholder"></span> menu</span> <h3 class="subnav-title-h3" style="position:relative;text-align:left;">section title h3</h3> </div> <div class="menu-wrapper"> <ul class="menu"> <li class="menu-item menu-item--l3"> <a href="/medicaid-chip/medicare-coordination/integrated-care-resources" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/174926">Integrated care resources</a> </li> <li class="menu-item menu-item--l3"> <a href="/medicaid-chip/medicare-coordination/avoidable-hospitalizations" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/181236">Initiative to reduce avoidable hospitalizations</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicaid-chip/medicare-coordination/financial-alignment" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/178246">Financial alignment initiative</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/medicaid-chip/medicare-coordination/integrity-institute" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/1315141">Medicaid Integrity Institute</a> </li> </ul> </div> </div> </li> <li class="menu-item menu-item--l2"> <span class="menu-item-element" aria-current="false">RG-Placeholder-1</span> </li> <li class="menu-item menu-item--l2"> <span class="menu-item-element" aria-current="false">IC-Placeholder-2</span> </li> </ul> </div> </li> <li class="menu-item menu-item--l1 menu-item--expanded"> <span class="menu-item-element" aria-current="false">Marketplace & Private Insurance</span> <div class="subnav-wrapper--1 ds-u-display--none"> <div class="subnav-header"> <span class="back-to-main ds-u-lg-display--none">Back to main menu</span> <h2 class="subnav-title-h2" style="position:relative;text-align:left;width:auto;height:auto;">section title h2</h2> </div> <ul class="menu"> <li class="menu-item menu-item--l2 menu-item--expanded"> <span class="menu-item-element" aria-current="false">About the Marketplace</span> <div class="subnav-wrapper--2 ds-u-display--none"> <div class="subnav-header"> <span class="back-to-l2 ds-u-lg-display--none">Back to <span class="l2-placeholder"></span> menu</span> <h3 class="subnav-title-h3" style="position:relative;text-align:left;">section title h3</h3> </div> <div class="menu-wrapper"> <ul class="menu"> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/marketplace/about/oversight" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/191061">Marketplace oversight</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/marketplace/about/affordable-care-act" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/191416">Affordable Care Act</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/marketplace/about/overview-exchanges" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/190921">Overview of the exchanges</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/about/exchange-coverage-maps" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/193086">Exchange coverage maps</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/about/medicare" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/179351">Medicare and the Marketplace</a> </li> </ul> </div> </div> </li> <li class="menu-item menu-item--l2 menu-item--expanded"> <span class="menu-item-element" aria-current="false">Private Health Insurance</span> <div class="subnav-wrapper--2 ds-u-display--none"> <div class="subnav-header"> <span class="back-to-l2 ds-u-lg-display--none">Back to <span class="l2-placeholder"></span> menu</span> <h3 class="subnav-title-h3" style="position:relative;text-align:left;">section title h3</h3> </div> <div class="menu-wrapper"> <ul class="menu"> <li class="menu-item menu-item--l3"> <a href="/marketplace/private-health-insurance/patient-bill-of-rights" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/192591">Patient鈥檚 Bill of Rights</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/private-health-insurance/medical-loss-ratio" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/190956">Medical loss ratio</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/private-health-insurance/annual-limits" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/191976">Annual limits</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/private-health-insurance/review-insurance-rates" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/192716">Review of insurance rates</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/private-health-insurance/market-rating-reforms" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/191816">Market rating</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/private-health-insurance/self-funded-non-federal-governmental-plans" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/191111">Self-funded, non-federal governmental plans</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/private-health-insurance/grandfathered-plans" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/191456">Grandfathered plans</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/private-health-insurance/health-reimbursement-arrangements" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/193216">Health Reimbursement Arrangements</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/private-health-insurance/coverage-young-adults" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/190931">Coverage for young adults</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/private-health-insurance/student-health-plans" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/190946">Student health plans</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/private-health-insurance/mental-health-parity-addiction-equity" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/192601">Mental health parity and addiction equity</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/private-health-insurance/prevention" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/191071">Prevention</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/private-health-insurance/consumer-protections-enforcement" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/192701">Consumer protections & enforcement</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/private-health-insurance/pre-existing-condition-plan" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/191056">Pre-existing condition insurance plan</a> </li> <li class="menu-item menu-item--l3"> <a href="https://www.healthcare.gov/glossary/qualifying-health-coverage" class="menu-item-element" aria-current="false">Qualifying Health Coverage (QHC)</a> </li> </ul> </div> </div> </li> <li class="menu-item menu-item--l2"> <span class="menu-item-element" aria-current="false">RG-Placeholder-2</span> </li> <li class="menu-item menu-item--l2 menu-item--expanded"> <span class="menu-item-element" aria-current="false">In-person assisters</span> <div class="subnav-wrapper--2 ds-u-display--none"> <div class="subnav-header"> <span class="back-to-l2 ds-u-lg-display--none">Back to <span class="l2-placeholder"></span> menu</span> <h3 class="subnav-title-h3" style="position:relative;text-align:left;">section title h3</h3> </div> <div class="menu-wrapper"> <ul class="menu"> <li class="menu-item menu-item--l3"> <a href="/marketplace/in-person-assisters/information-partners" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/2078851">Information for Partners</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/marketplace/in-person-assisters/outreach-education" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/2073436">Assister outreach & education</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/marketplace/in-person-assisters/applications-forms-notices" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/2073441">Applications, forms, & notices</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/marketplace/in-person-assisters/programs-procedures" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/2073446">Assister programs & procedures</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/marketplace/in-person-assisters/technical-resources" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/2073231">Assister technical resources</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/marketplace/in-person-assisters/training-webinars" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/2073451">Assister training & webinars</a> </li> </ul> </div> </div> </li> <li class="menu-item menu-item--l2 menu-item--expanded"> <span class="menu-item-element" aria-current="false">Agents & Brokers</span> <div class="subnav-wrapper--2 ds-u-display--none"> <div class="subnav-header"> <span class="back-to-l2 ds-u-lg-display--none">Back to <span class="l2-placeholder"></span> menu</span> <h3 class="subnav-title-h3" style="position:relative;text-align:left;">section title h3</h3> </div> <div class="menu-wrapper"> <ul class="menu"> <li class="menu-item menu-item--l3"> <a href="/marketplace/agents-brokers/resources" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/192876">Resources for Agent & Brokers</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/agents-brokers/registration-training" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/1290426">Registration & training</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/agents-brokers/open-enrollment" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/193226">Open enrollment</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/agents-brokers/direct-enrollment-partners" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/1550226">Direct enrollment partners</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/agents-brokers/general-resources" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/185021">General resources</a> </li> <li class="menu-item menu-item--l3"> <a href="https://www.youtube.com/playlist?list=PLaV7m2-zFKpgUK9AqdbnOdW69-WwodvRj" class="menu-item-element" aria-current="false">Video Learning Center</a> </li> <li class="menu-item menu-item--l3"> <a href="https://www.agentbrokerfaq.cms.gov/s/" class="menu-item-element" aria-current="false">Agent & Broker FAQ</a> </li> <li class="menu-item menu-item--l3"> <a href="/files/document/agent/broker-help-desks.pdf" class="menu-item-element" aria-current="false" data-drupal-link-system-path="media/112386">Marketplace help desk & call centers</a> </li> <li class="menu-item menu-item--l3"> <a href="https://data.healthcare.gov/ffm_ab_registration_lists" class="menu-item-element" aria-current="false">Registration Completion List</a> </li> <li class="menu-item menu-item--l3"> <a href="https://data.healthcare.gov/ab-registration-tracker/" class="menu-item-element" aria-current="false">Marketplace Registration Tracker</a> </li> <li class="menu-item menu-item--l3"> <a href="https://data.healthcare.gov/ab-suspension-and-termination-list" class="menu-item-element" aria-current="false">AB Suspension & Termination List</a> </li> <li class="menu-item menu-item--l3"> <a href="https://localhelp.healthcare.gov/" class="menu-item-element" aria-current="false">Find local help</a> </li> <li class="menu-item menu-item--l3"> <a href="https://data.healthcare.gov/issuer-partner-lookup" class="menu-item-element" aria-current="false">Issuer and direct enrollment partner directory</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/agents-brokers/help-on-demand" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/193196">Help on demand</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/agents-brokers/shop-resources" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/193096">SHOP Resources</a> </li> </ul> </div> </div> </li> <li class="menu-item menu-item--l2 menu-item--expanded"> <span class="menu-item-element" aria-current="false">Health Plans & Issuers</span> <div class="subnav-wrapper--2 ds-u-display--none"> <div class="subnav-header"> <span class="back-to-l2 ds-u-lg-display--none">Back to <span class="l2-placeholder"></span> menu</span> <h3 class="subnav-title-h3" style="position:relative;text-align:left;">section title h3</h3> </div> <div class="menu-wrapper"> <ul class="menu"> <li class="menu-item menu-item--l3"> <a href="/marketplace/health-plans-issuers/qualified-health-plan-certification" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/191371">Qualified health plan certification </a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/health-plans-issuers/summary-benefits-coverage" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/191461">Summary of benefits & coverage</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/marketplace/health-plans-issuers/insurance-programs" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/192101">Insurance programs</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/marketplace/health-plans-issuers/premium-stabilization-programs" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/191326">Premium stabilization programs</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/health-plans-issuers/insurance-market-reforms" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/191421">Health insurance market reforms</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/health-plans-issuers/minimum-essential-coverage" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/192891">Minimum essential coverage</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace-private-insurance/health-plans-issuers/pbm-drug-pricing-review" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/2088761">Drug pricing & rebate review</a> </li> </ul> </div> </div> </li> <li class="menu-item menu-item--l2 menu-item--expanded"> <span class="menu-item-element" aria-current="false">Employers & sponsors</span> <div class="subnav-wrapper--2 ds-u-display--none"> <div class="subnav-header"> <span class="back-to-l2 ds-u-lg-display--none">Back to <span class="l2-placeholder"></span> menu</span> <h3 class="subnav-title-h3" style="position:relative;text-align:left;">section title h3</h3> </div> <div class="menu-wrapper"> <ul class="menu"> <li class="menu-item menu-item--l3"> <a href="https://www.healthcare.gov/small-businesses/other-coverage" class="menu-item-element" aria-current="false">Coverage</a> </li> <li class="menu-item menu-item--l3"> <a href="https://www.healthcare.gov/small-businesses/choose-and-enroll/shop-marketplace-overview" class="menu-item-element" aria-current="false">Regulation & guidance</a> </li> <li class="menu-item menu-item--l3"> <a href="https://www.healthcare.gov/small-businesses/choose-and-enroll/qualify-for-shop-marketplace" class="menu-item-element" aria-current="false">Small business tax credit & premium assistance</a> </li> <li class="menu-item menu-item--l3"> <a href="https://www.healthcare.gov/small-businesses/choose-and-enroll/appeal-a-shop-decision" class="menu-item-element" aria-current="false">Appeals</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/employers-sponsors/small-business-health-options-program-shop" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/192901">Small Business Health Options Program (SHOP)</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/employers-sponsors/early-retiree-reinsurance-program" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/191651">Early retiree reinsurance program</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/employer-initiatives" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/192916">Employer initiatives</a> </li> </ul> </div> </div> </li> <li class="menu-item menu-item--l2 menu-item--expanded"> <span class="menu-item-element" aria-current="false">States</span> <div class="subnav-wrapper--2 ds-u-display--none"> <div class="subnav-header"> <span class="back-to-l2 ds-u-lg-display--none">Back to <span class="l2-placeholder"></span> menu</span> <h3 class="subnav-title-h3" style="position:relative;text-align:left;">section title h3</h3> </div> <div class="menu-wrapper"> <ul class="menu"> <li class="menu-item menu-item--l3"> <a href="/marketplace/states/state-marketplace-resources" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/190916">Planning & establishing a Marketplace</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/states/territory-cooperative-agreements" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/190926">Territory cooperative agreements</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/states/early-innovator-program" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/191691">Early innovator program</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/states/state-flexibility-stabilize-market" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/193246">State flexibility to stabilize the Market </a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/states/creating-competitive-marketplace" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/192231">Exchange establishment grants</a> </li> <li class="menu-item menu-item--l3"> <a href="https://www.healthcare.gov/coverage/pre-existing-conditions" class="menu-item-element" aria-current="false">Pre-existing condition insurance plan</a> </li> </ul> </div> </div> </li> <li class="menu-item menu-item--l2 menu-item--expanded"> <span class="menu-item-element" aria-current="false">Resources</span> <div class="subnav-wrapper--2 ds-u-display--none"> <div class="subnav-header"> <span class="back-to-l2 ds-u-lg-display--none">Back to <span class="l2-placeholder"></span> menu</span> <h3 class="subnav-title-h3" style="position:relative;text-align:left;">section title h3</h3> </div> <div class="menu-wrapper"> <ul class="menu"> <li class="menu-item menu-item--l3"> <a href="/marketplace/resources/about-us" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/192721">About Us</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/marketplace/resources/data" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/191741">Data resources</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/resources/forms-reports-other" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/190966">Forms, reports, & other resources</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/resources/letters" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/191646">Letters</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/resources/regulations-guidance" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/191366">Regulations & Guidance</a> </li> <li class="menu-item menu-item--l3"> <a href="/marketplace/resources/training" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/191466">Training resources</a> </li> </ul> </div> </div> </li> </ul> </div> </li> <li class="menu-item menu-item--l1 menu-item--expanded"> <span class="menu-item-element" aria-current="false">Priorities</span> <div class="subnav-wrapper--1 ds-u-display--none"> <div class="subnav-header"> <span class="back-to-main ds-u-lg-display--none">Back to main menu</span> <h2 class="subnav-title-h2" style="position:relative;text-align:left;width:auto;height:auto;">section title h2</h2> </div> <ul class="menu"> <li class="menu-item menu-item--l2 menu-item--expanded"> <span class="menu-item-element" aria-current="false">Innovation Center</span> <div class="subnav-wrapper--2 ds-u-display--none"> <div class="subnav-header"> <span class="back-to-l2 ds-u-lg-display--none">Back to <span class="l2-placeholder"></span> menu</span> <h3 class="subnav-title-h3" style="position:relative;text-align:left;">section title h3</h3> </div> <div class="menu-wrapper"> <ul class="menu"> <li class="menu-item menu-item--l3"> <a href="/priorities/innovation/overview" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/2090631">Overview</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/priorities/innovation/about" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/2074091">About</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/priorities/innovation/key-concepts" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/2072461">Key Concepts</a> </li> <li class="menu-item menu-item--l3"> <a href="/priorities/innovation-center/model-data" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/2087691">Model Data</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/priorities/innovation-center/value-based-care-spotlight" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/2082926">Value-Based Care Spotlight</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/priorities/innovation/models" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/2072436">Innovation Models</a> </li> <li class="menu-item menu-item--l3"> <a href="/priorities/innovation/where-innovation-happening" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/2072451">Where Innovation is Happening</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/priorities/innovation/evaluation-research-reports" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/2072446">Evaluations & Research Reports</a> </li> </ul> </div> </div> </li> <li class="menu-item menu-item--l2 menu-item--expanded"> <span class="menu-item-element" aria-current="false">Health Equity</span> <div class="subnav-wrapper--2 ds-u-display--none"> <div class="subnav-header"> <span class="back-to-l2 ds-u-lg-display--none">Back to <span class="l2-placeholder"></span> menu</span> <h3 class="subnav-title-h3" style="position:relative;text-align:left;">section title h3</h3> </div> <div class="menu-wrapper"> <ul class="menu"> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/priorities/health-equity/c2c" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/1974361">Coverage to Care</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/priorities/health-equity/minority-health" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/1620916">Minority health</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/priorities/health-equity/c2c/es" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/2072591">Cobertura de atenci贸n</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/priorities/health-equity/grants-awards" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/1612961">Grants & awards</a> </li> </ul> </div> </div> </li> <li class="menu-item menu-item--l2 menu-item--expanded"> <span class="menu-item-element" aria-current="false">Recent Legislation</span> <div class="subnav-wrapper--2 ds-u-display--none"> <div class="subnav-header"> <span class="back-to-l2 ds-u-lg-display--none">Back to <span class="l2-placeholder"></span> menu</span> <h3 class="subnav-title-h3" style="position:relative;text-align:left;">section title h3</h3> </div> <div class="menu-wrapper"> <ul class="menu"> <li class="menu-item menu-item--l3"> <a href="/inflation-reduction-act-and-medicare" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/1621896">Inflation Reduction Act and Medicare</a> </li> <li class="menu-item menu-item--l3"> <a href="/nosurprises" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/1573261">No Surprises Act</a> </li> </ul> </div> </div> </li> <li class="menu-item menu-item--l2 menu-item--expanded"> <span class="menu-item-element" aria-current="false">Key Initiatives</span> <div class="subnav-wrapper--2 ds-u-display--none"> <div class="subnav-header"> <span class="back-to-l2 ds-u-lg-display--none">Back to <span class="l2-placeholder"></span> menu</span> <h3 class="subnav-title-h3" style="position:relative;text-align:left;">section title h3</h3> </div> <div class="menu-wrapper"> <ul class="menu"> <li class="menu-item menu-item--l3"> <a href="/priorities/key-initiatives/opioids" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/1620416">Opioids</a> </li> <li class="menu-item menu-item--l3"> <a href="/priorities/key-initiativess/flu" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/1399001">Flu</a> </li> <li class="menu-item menu-item--l3"> <a href="/priorities/key-initiatives/medicare-open-enrollment-partner-resources" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/180361">Medicare Open Enrollment</a> </li> <li class="menu-item menu-item--l3"> <a href="/outreach-and-education/reach-out/find-tools-to-help-you-help-others/open-enrollment-outreach-and-media-materials" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/180386">Medicare OE partner resources</a> </li> <li class="menu-item menu-item--l3"> <a href="https://www.healthcare.gov/quick-guide/dates-and-deadlines" class="menu-item-element" aria-current="false">Marketplace Open Enrollment</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a 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ds-u-lg-display--none">Back to <span class="l2-placeholder"></span> menu</span> <h3 class="subnav-title-h3" style="position:relative;text-align:left;">section title h3</h3> </div> <div class="menu-wrapper"> <ul class="menu"> <li class="menu-item menu-item--l3"> <a href="https://cmsnationaltrainingprogram.cms.gov/resources" class="menu-item-element" aria-current="false">National Training Program resources</a> </li> <li class="menu-item menu-item--l3"> <a href="https://cmsnationaltrainingprogram.cms.gov/?q=global-search&combine=classroom%20modules" class="menu-item-element" aria-current="false">Class modules</a> </li> </ul> </div> </div> </li> <li class="menu-item menu-item--l2 menu-item--expanded"> <span class="menu-item-element" aria-current="false">Partner outreach resources</span> <div class="subnav-wrapper--2 ds-u-display--none"> <div class="subnav-header"> <span class="back-to-l2 ds-u-lg-display--none">Back to <span class="l2-placeholder"></span> menu</span> <h3 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class="subnav-title-h3" style="position:relative;text-align:left;">section title h3</h3> </div> <div class="menu-wrapper"> <ul class="menu"> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/training-education/open-door-forums/about" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/172171">About Open Door Forums</a> </li> <li class="menu-item menu-item--l3"> <a href="/training-education/open-door-forums/ambulance" title="The Ambulance Open Door Forum (ODF) addresses issues related to the payment, billing, coverage and delivery of services in the ambulance industry." class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/172296">Ambulance</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/esrd" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/172241">End-Stage Renal Disease (ESRD) Dialysis Facility Care Compare</a> </li> <li class="menu-item 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</div> </li> <li class="menu-item menu-item--l2 menu-item--expanded"> <span class="menu-item-element" aria-current="false">Learn More</span> <div class="subnav-wrapper--2 ds-u-display--none"> <div class="subnav-header"> <span class="back-to-l2 ds-u-lg-display--none">Back to <span class="l2-placeholder"></span> menu</span> <h3 class="subnav-title-h3" style="position:relative;text-align:left;">section title h3</h3> </div> <div class="menu-wrapper"> <ul class="menu"> <li class="menu-item menu-item--l3"> <a href="/training-education/learn/attend-events" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/178031">Attend events</a> </li> <li class="menu-item menu-item--l3"> <a href="/training-education/learn/find-resources" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/178121">Find resources</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/training-education/learn/get-training" 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style="position:relative;text-align:left;">section title h3</h3> </div> <div class="menu-wrapper"> <ul class="menu"> <li class="menu-item menu-item--l3"> <a href="/training-education/find-provider-type/physicians-other-health-professionals" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/178186">Physicians & other health professionals</a> </li> <li class="menu-item menu-item--l3"> <a href="/training-education/find-provider-type/facilities" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/178136">Facilities</a> </li> <li class="menu-item menu-item--l3"> <a href="/training-education/find-provider-type/health-drug-plans" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/178181">Health & drug plans</a> </li> <li class="menu-item menu-item--l3 menu-item--collapsed"> <a href="/training-education/find-provider-type/employers-unions" class="menu-item-element" aria-current="false" data-drupal-link-system-path="node/178211">Employers & unions</a> </li> </ul> </div> </div> </li> </ul> </div> </li> </ul> </nav> </div> </div> </div> </div> </div> <div class="header-breadcrumb-wrapper ds-u-display--none ds-u-md-display--block cms-tracker--breadcrumbs"> <div class="ds-l-container"> <div class="ds-l-row"> <div class="ds-l-col--12 ds-u-display--flex ds-u-justify-content--between ds-u-align-items--center"> <div id="block-cms-evo-breadcrumbs" class="block block-system block-system-breadcrumb-block"> <div class="content"> <span class="create-date"> </span> <nav class="breadcrumb" aria-label="Breadcrumb"> <ul class="menu cms-evo-unstyled-list"> <li> <a href="/" title="CMS Home" class="linked-breadcrumb"><i class="fas fa-home"></i></a> <i class="fas fa-angle-right"></i> </li> <li> Medicare <i class="fas fa-angle-right"></i> </li> <li> Forms & notices <i class="fas fa-angle-right"></i> </li> <li> CMS forms list </li> </ul> </nav> </div> </div> </div> </div> </div> </div> </header> <div id="page-wrapper" class="layout-builder-enabled-view-mode section_page"> <div id="page"> <main id="skipNavTarget" role="main"> <div id="main-wrapper" class="clearfix"> <div class="ds-l-container"> <div class="ds-l-row"> <div class="ds-l-col--12"> <div class="region region-cms-page-menu-block-header"> </div> </div> </div> </div> <div id="main" class="clearfix"> <div> <inner> <div class="ds-l-container"> <div class="ds-l-row"> <div class="ds-l-col--12"> <div class="region region-content"> <div data-drupal-messages-fallback class="hidden"></div> <div id="block-cms-evo-pagetitle" class="block block-core block-page-title-block"> <div class="content"> <span class="create-date"> </span> <h1 class="ds-u-visibility--screen-reader page-title"><span class="field field--name-title field--type-string field--label-visually_hidden">CMS Forms List <div class="title-border"></div></span> </h1> <div class="title-border"></div> </div> </div> </div> </div> </div> </div> <div id="block-cms-evo-content" class="block block-system block-system-main-block"> <div class="content"> <span class="create-date"> </span> <div class="node node--type-section-page node--view-mode-full clearfix"> <div class="node__content clearfix"> <div class="subsite_body"> <div class="layout--constrained section--bg-style-none section--bg-color-none layout layout--onecol-section"> <div class="ds-l-container"> <div class="ds-l-row"> <div class="layout__column ds-l-col--12 cms-global-center"> <div class="block block-layout-builder block-field-blocknodesection-pagetitle"> <div class="content"> <span class="create-date"> </span> <span class="field field--name-title field--type-string field--label-visually_hidden alternate-page-title ds-u-margin-bottom--0 ds-u-font-size--3xl ds-u-font-weight--semibold">CMS Forms List</span> </div> </div> <div class="block block-layout-builder block-field-blocknodesection-pagebody"> <div class="content"> <span class="create-date"> </span> <div class="field field--name-body field--type-text-with-summary field--label-hidden field__item"><div class="rxbodyfield"> <p>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.</p> </div></div> </div> </div> <div class="block block-layout-builder block-field-blocknodesection-pagefield-dynamic-list-table-ref"> <div class="content"> <span class="create-date"> </span> <div class="field field--name-field-dynamic-list-table-ref field--type-entity-reference field--label-hidden field__item"> <div id="taxonomy-term-31831" class="taxonomy-term vocabulary-dynamic-osora-osso"> <div class="content"> </div> </div> <div class="ds-u-margin-y--1"> <table id="dynamic_list_items_table" data-dltid="31831" class="responsive-enabled stripe" data-striping="1"> <thead> <tr> <th>Form #</th> <th>Form Title</th> <th>Revision Date</th> </tr> </thead> <tbody> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms012237">CMS 10003-NDMCP</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> NOTICE OF DENIAL OF MEDICAL COVERAGE/PAYMENT ("INTEGRATED DENIAL NOTICE") </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2013-06-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms056691">CMS 10036</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Inpatient Rehabilitation Facility-Patient Assessment Instrument </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2006-01-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms019508">CMS 10055</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> SKILLED NURSING FACILITY ADVANCED BENEFICIARY NOTICE </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms1189117">CMS 10069</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Medicare Waiver Demonstration Application </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2013-12-31 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms1207289">CMS 10095DENC</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Detailed Explanation of Non-Coverage </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2006-12-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms020275">CMS 10095NOMNC</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> NOTICE OF MEDICARE NON-COVERAGE </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2006-12-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms1193148">CMS 10106 PDF</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> 1-800-Medicare Authorization to Disclosure Personal Health Information </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2023-05-22 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms013118">CMS 10114</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> NATIONAL PROVIDER IDENTIFIER (NPI) APPLICATION/UPDATE FORM </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2021-08-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms019517">CMS 10123</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> EXPEDITED REVIEW NOTICE-NOTICE OF MEDICARE PROVIDER NON-COVERAGE </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2008-02-29 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms019520">CMS 10124</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> EXPEDITED REVIEW NOTICE-DETAILED EXPLANATION OF NON-COVERAGE </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2008-02-29 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms1184634">CMS 10125</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> DME Information Form - External Infusion Pumps DME 09.03 </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2017-02-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms1184635">CMS 10126</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> DME Information Form - Enteral and Parenteral Nutrition DME 10.03 </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2017-02-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms056137">CMS 10146</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Notice of Denial of Medicare Prescription Drug Coverage English/Spanish </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2019-01-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms058773">CMS 10156</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Retiree Drug Subsidy </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2005-08-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms1215291">CMS 10164</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Centers for Medicare and Medicaid Services EDI Registration Form; and EDI Enrollment Form </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2024-08-26 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/httpswwwcmsgovmedicarecms-formscms-formscms-forms-list/cms-10175">CMS 10175</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Electronic File Interchange Organization (EFIO) Certification Statement </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2022-03-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms1198447">CMS 10198</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Creditable Coverage Disclosure to CMS On-line Form and Instructions </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2017-12-27 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms1207001">CMS 10221</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Independent Diagnostic Testing Facilities-Site Investigation </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2024-01-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms1214081">CMS 10252</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> DATA USE AGREEMENT (DUA) CERTFICATE OF DISPOSITION (COD) FOR DATA ACQUIRED FROM THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2022-04-27 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms1220725">CMS 10269</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> CMN Positive Airway Pressure (PAP)Devices for Obstructive Sleep Apnea </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2009-12-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms1240839">CMS 10287</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Medicare Quality of Care Complaint Form </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2015-11-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-list/cms-10798">CMS 10798</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Application for Enrollment in Part B Immunosuppressive Drug Coverage </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2023-02-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/forms-notices/cms-forms-list/cms-10883">CMS 10883</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> ADA Dental Claim Form </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2024-08-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms012169">CMS 116</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> CLINICAL LABORATORY IMPROVEMENT AMENDMENTS OF 1988 (CLIA) APPLICATION FOR CERTIFICATION </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2020-04-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms1196256">CMS 1450</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> UB-04 Uniform Bill </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2007-03-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms012949">CMS 1490S</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> PATIENT'S REQUEST FOR MEDICAL PAYMENT (English/Spanish) </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2021-06-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms1188854">CMS 1500</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Health Insurance Claim Form </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2012-02-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms049121">CMS 1515A-OBSOLETE</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> HHA Functional Assessment Instrumental </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2013-05-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms011722">CMS 1539</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 1984-07-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms013070">CMS 1541B</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN EMERGENCY CASES INVESTIGATION REPORT </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2014-09-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms013075">CMS 1557</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> SURVEY REPORT FORM - CLIA </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2021-02-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms012196">CMS 1561</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> HEALTH INSURANCE BENEFIT AGREEMENT </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2024-01-19 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms019485">CMS 1561A</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> HEALTH INSURANCE BENEFIT AGREEMENT-RURAL HEALTH CLINIC </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2024-01-19 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms012447">CMS 1563</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Monthly Intermediary Report on Medicare Secondary Payer Savings </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 1997-11-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms013079">CMS 1564</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> MONTHLY CARRIER REPORT ON MEDICARE SECONDARY PAYER SAVINGS </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 1997-11-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms012203">CMS 1572</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> HHA SURVEY REPORT </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2022-07-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms017352">CMS 1592</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> SMI PREMIUM ACCTG FORM </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 1986-07-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms013081">CMS 1666</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> REGIONAL OFFICE REQUEST FOR ADDITIONAL INFORMATION </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 1980-04-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms012207">CMS 1696</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> APPOINTMENT OF REPRESENTATIVE </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2024-09-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms019489">CMS 1728</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> HOME HEALTH AGENCY COST REPORT </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2001-06-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms017353">CMS 1763</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Request for Termination of Premium Hospital Insurance of Supplementary Medical Insurance </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2022-01-31 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms013088">CMS 1771</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> ATTENDING PHYSICIANS STATEMENT AND DOCUMENTATION FOR MEDICARE EMERGENCY </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 1977-09-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms012182">CMS 179</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2024-01-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms017337">CMS 18-F-5</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> APPLICATION FOR PART A (HOSPITAL INSURANCE) </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2023-06-30 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms012215">CMS 1856</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Request for Certification in the Medicare and/or Medicaid Program to Provide Outpatient Physical Therapy and/or Speech Pathology Services </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2006-12-11 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms013094">CMS 1880</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> REQUEST FOR CERTIFICATION AS SUPPLIER OF PORTABLE XRAY SERVICES </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2018-05-31 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms012220">CMS 1882</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> PORTABLE XRAY SURVEY REPORT </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2009-02-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms017354">CMS 1957</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> SSO REPORT OF STATE BUY IN PROBLEM </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2018-04-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms017355">CMS 1960</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> REQUEST FOR EVIDENCE OF MEDICAL NECESSITY </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 1969-05-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms013110">CMS 1980</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> CARRIER OR INTERMEDIARY REQUEST FOR SSO ASSISTANCE </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 1978-03-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms019494">CMS 1984</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> HOSPICE COST REPORT </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2005-02-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms020383">CMS 20017</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> ADVISORY PANEL ON HOSPITAL OUTPATIENT PAYMENT </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2017-04-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms020385">CMS 20027</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> MEDICARE REDETERMINATION REQUEST FORM </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 0019-07-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms020388">CMS 20031</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> TRANSFER (ASSIGNMENT) OF APPEAL RIGHTS </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2018-03-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms020393">CMS 20033</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> MEDICARE RECONSIDERATION REQUEST FORM </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 0019-07-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms20037">CMS 20037</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> APPLICATION FOR ACCESS TO CMS COMPUTER SYSTEMS </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2010-06-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms056040">CMS 20040</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Regional Office Meeting/Speaker Request Form </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 0005-12-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms056041">CMS 20041</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Speech Invitation Request Background Information </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 0005-12-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms20056">CMS 20056</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Medicare Adminstration Observation </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2013-02-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms009554">CMS 2007</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> PROVIDER TIE IN NOTICE </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 1982-03-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms20134">CMS 20134</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Medicare Enrollment Application - Medicare Diabetes Prevention Program (MDPP) Suppliers </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2018-01-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/httpscmsgovmedicarecms-formscms-formscms-forms-list/medicare-easy-pay-premium-statement">CMS 20143</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Medicare Easy Pay Premium Statement </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2024-05-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms019497">CMS 2088-92</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> OUTPATIENT REHAB PROVIDER COST REPORT </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2004-12-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms008840">CMS 209</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> LABORATORY PERSONNEL REPORT (CLIA) </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2021-01-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms019162">CMS 216</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> ORGAN PROCUREMENT ORGANIZATION-HISTO-COMPATIBILITY LAB STATEMENT OF REIMBURSABLE COSTS </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2005-11-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms017356">CMS 2178</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> HI/SMI ENTITLEMENT PROBLEM REFERRAL </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2006-09-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms019164">CMS 222</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> INDEPENDENT RURAL HEALTH CLINIC WORKSHEET </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2005-01-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms017357">CMS 2384</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> THIRD PARTY PREMIUM BILLING REQUEST, MEDICARE </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2018-03-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms019499">CMS 2540-96</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> SNF AND SNF HEALTH CARE COMPLEX COST REPORT </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2006-05-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms019505">CMS 2552-96</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> COST REPORT FOR ELECTRONIC FILING OF HOSPITALS </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2004-05-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms008860">CMS 2567</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2022-03-18 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms009564">CMS 2567B</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> POST-CERTIFICATION REVISIT REPORT </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 1992-09-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms019166">CMS 265</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> INDEPENDENT RENAL DIALYSIS FACILITY COST REPORT </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2005-03-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms017358">CMS 2690</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> REQ FOR CANCELLATION OF SMI </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 1978-03-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms008867">CMS 2728</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> ESRD MEDICAL EVIDENCE REPORT MEDICARE ENTITLEMENT AND/OR PATIENT REGISTRATION </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2024-06-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms009579">CMS 2744A</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> ESRD FACILITY SURVEY (DIALYSIS UNIT ONLY) </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2020-07-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms020293">CMS 2744B</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM ESRD FACILITY SURVEY (TRANSPLANT CENTERS ONLY) </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2020-07-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms008869">CMS 2746</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> ESRD DEATH NOTIFICATION </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2024-05-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms008870">CMS 2786M</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Worksheet for Determining Evacuation Capability - ICF-IID (Existing Facilities Only) 2012 Life Safety Code </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2018-07-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms009335">CMS 2786R</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Fire Safety Survey Report - Health Care 2012 Life Safety Code </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2018-07-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms009393">CMS 2786T</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Fire Safety Evaluation System - Health Care 2012 Life Safety Code </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2022-10-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms009395">CMS 2786U</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Fire Safety Survey Report - ASC & ESRD 2012 Life Safety Code </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2018-07-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms008873">CMS 2786V</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Fire Safety Survey Report - ICF-IID (Small Facilities) 2012 Life Safety Code </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2018-07-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms008881">CMS 2786W</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Fire Safety Survey Report - ICF-IID (Large Facilities) 2012 Life Safety Code </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2018-07-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms048764">CMS 2786X</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Fire Safety Survey Report - ICF-IID (Apartment House) 2012 Life Safety Code </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2018-07-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms009403">CMS 2786Y</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Fire Safety Evaluation System - ICF-IID (Small Facilities) 2012 Life Safety Code </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2018-07-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms009406">CMS 2802</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> REQUEST FOR VALIDATION OF ACCREDITATION </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2011-02-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms009494">CMS 2802B</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR HOSPICE </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2011-02-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms009506">CMS 2802C</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR HOME HEALTH AGENCY </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2019-03-31 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms009514">CMS 2802D</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR AMBULATORY SURGICAL CENTER </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2011-02-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms009532">CMS 2802E</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> REQUEST FOR VALIDATION OF ACCREDITATION FOR CRITICAL ACCESS HOSPITAL SURVEY </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2011-02-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms1254389">CMS 2802F</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Authorization for State Agency Psychiatric Hospital Validation Survey </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2011-11-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms019459">CMS 287</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> HOME OFFICE COST STATEMENT </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 1995-11-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms009585">CMS 2878</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> ACCREDITED HOSPITAL ALLEGATIONS REPORT </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 1986-04-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms008849">CMS 29</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> VERIFICATION OF CLINIC DATA ? RURAL HEALTH CLINIC PROGRAM </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2022-06-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms008815">CMS 3070G</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> ICF/IID Survey Report </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2013-03-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms008818">CMS 3070H</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> ICF/IID Deficiencies Report </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2013-03-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms008821">CMS 3070I</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> INDIVIDUAL OBSERVATION WORKSHEET </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 1995-10-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms019462">CMS 339</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> PROVIDER COST REPORT REIMBURSEMENT QUESTIONNAIRE </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2006-04-30 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms008714">CMS 359</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> CORF REPORT FOR CERTIFICATION TO PARTICIPATE IN MEDICARE </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2021-04-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms008682">CMS 36</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> CONSENT FOR HOME VISIT (English/Spanish) </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 1990-12-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicarecms-formscms-formscms-forms-list/comprehensive-outpatient-rehabilitation-facility-survey-report-0">CMS 360</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY SURVEY REPORT </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2021-04-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms008696">CMS 36P</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> CONSENT FOR HOME VISIT FOR PACE SERVICES EVALUATION </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2002-07-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms008717">CMS 370</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> HEALTH INSURANCE BENEFITS AGREEMENT-AMBULATORY SURGICAL CENTER </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2002-04-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms008718">CMS 377</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> AMBULATORY SURGICAL CENTER REQUEST FOR CERTIFICATION IN MEDICARE </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 0021-02-28 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms008774">CMS 379</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> FINANCIAL STATEMENT OF DEBTOR </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2007-07-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms008787">CMS 381</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> MODEL LETTER REQUESTING IDENTIFICATION OF EXTENSION LOCATIONS </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2024-08-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms1199192">CMS 383</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> HEALTH INSURANCE CASE SUMMARY </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 1982-12-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms008803">CMS 384</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> QIO CASE SUMMARY </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 1992-03-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms007776">CMS 4040</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> REQUEST FOR ENROLLMENT IN SUPPLEMENTARY MEDICAL INSURANCE (English / Spanish) </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2023-09-30 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms017339">CMS 40B</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Application for Enrollment in Medicare - Part B (Medical Insurance) </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2024-01-10 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms1184680">CMS 416</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Early ad Periodic Screening Diagnostic and Treatment Participation Report </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 1999-06-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms020294">CMS 417</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> HOSPICE REQUEST FOR CERTIFICATION IN MEDICARE </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2021-11-30 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms017342">CMS 43</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> APPLICATION FOR HOSPITAL INSURANCE BENEFITS FOR INDIVIDUALS WITH END STAGE RENAL DISEASE </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2023-02-28 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms006712">CMS 437</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> PSYCHIATRIC UNIT CRITERIA WORKSHEET </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2026-09-30 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms006741">CMS 437A</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> REHAB UNIT CRITERIA WORKSHEET </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2026-09-30 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms006760">CMS 437B</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> REHAB HOSPITAL CRITERIA WORKSHEET </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2026-09-30 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms007566">CMS 460</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> MEDICARE PARTICIPATING PHYSICIAN OR SUPPLIER AGREEMENT </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2022-11-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms007663">CMS 462L</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> ADVERSE ACTI0N EXTRACT FOR SNFs AND NFs </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 1995-07-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms007682">CMS 484</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> CERTIFICATE OF MEDICAL NECESSITY - Oxygen DME 484.5 </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2017-02-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms017348">CMS 500</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> MEDICARE PREMIUM BILL </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2024-05-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms006171">CMS 576</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Organ Procurement Request for Designation as an OPO </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 1993-01-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms006189">CMS 576A</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Health Insurance Benefits Agreement with Organ Procurement Organization </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2006-06-30 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms006198">CMS 588</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Electronic Funds Transfer (EFT) Authorization Agreement </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2023-11-02 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms048895">CMS 632FOI</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> FREEDOM OF INFORMATION ACT REQUEST </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2013-03-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms006200">CMS 633</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Invoice of Fees for FOIA Services </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2008-01-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms006388">CMS 643 (28 KB)</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Hospice Survey AND Deficiencies Report </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2008-06-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms006581">CMS 671</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> LTC Facility Application for Medicare/Medicaid </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2023-09-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms006583">CMS 672</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Resident Census and Conditions of Residents </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2012-05-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms006601">CMS 724</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Medicare/Medicaid Psychiatric Hospital Survey Data </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 1994-09-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms006605">CMS 725</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Surveyor Worksheet for Psychiatric Hospital Review:Two Special Conditions </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 1994-09-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms006607">CMS 726</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> CMS Death Record Review Data Sheet </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 1994-09-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms006611">CMS 727</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> CMS Nursing Complement Data </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 1994-09-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms006613">CMS 728</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> CMS Staff Data </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 1994-09-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms006615">CMS 729</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Data Collection Medical Staff Coverage </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 1994-09-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms006618">CMS 801</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Offsite Survey Prep Worksheet </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 1995-07-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms006620">CMS 802</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Roster/Sample Matrix </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2023-10-24 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms006633">CMS 807</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Surveyor Notes Worksheet </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2024-03-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms019468">CMS 820</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> IN-CENTER HEMODIALYSIS (HD) CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2005 </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2005-01-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms019471">CMS 821</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> PERITONEAL DIALYSIS CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2005 </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2005-01-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms006634">CMS 838</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Medicare Credit Balance Reporting Requirements </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2003-10-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms006674">CMS 846</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Certificate of Medical Necessity - Pneumatic Compression Devices DME 04.04B </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2017-02-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms006677">CMS 847</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Certificate of Medical Necessity - Osteogenesis Stimulators - DME 04.04C </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2017-02-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms006684">CMS 848</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Certificate of Medical Necessity - Transcutaneous Electrical Nerve Stimulator (TENS) - DME 06.03B </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2017-02-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms006687">CMS 849</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Certificate of Medical Necessity - Seat Lift Mechanisms - DME 07.03A </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2017-02-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms006700">CMS 854</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Certificate of Medical Necessity - DME 11.02 </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2017-02-02 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms019475">CMS 855A</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Medicare Enrollment Application - Institutional Providers </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2024-09-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms019476">CMS 855B</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Medicare Enrollment Application - Clinics/Group Practices and Certain Other Suppliers </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2021-03-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms019477">CMS 855I</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Medicare Enrollment Application - Physicians and Non-Physician Practitioners </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2023-05-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms1249384">CMS 855O</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Medicare Enrollment Application - Registration For Eligible Ordering and Referring Physicians and Non-Physician Practitioners </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2023-09-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms019480">CMS 855S</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2023-12-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms009718">CMS L564</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> REQUEST FOR EMPLOYMENT INFORMATION </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2023-09-30 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms045942">CMS R-0235A (35 KB)</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Addendum to Data Use Agreement (DUA) </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2020-06-11 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms045945">CMS R-0235L (64 KB)</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Data Use Agreement (DUA)- Limited Data Sets </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2020-06-11 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms057233">CMS R-0235M</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Medicaid Agency Data Use Agreement </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2007-07-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms057714">CMS R-0235MA</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Addendum to the Medicaid State Agency Data Use Agreement </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2006-03-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms060976">CMS R-0235MC</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Compliance Plan for Accounting for Disclosures of Privacy Protected Data Released From a System of Records (SOR) Housed in a State-Located Server </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2006-03-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms045948">CMS R-0235U (48 KB)</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Data Use Agreement (DUA)- Update to Existing DUA </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2020-06-11 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms012932">CMS R-131</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> ADVANCE BENEFICIARY NOTICE (ABN) </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2011-03-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms012941">CMS R-193</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> IMPORTANT MESSAGE FROM MEDICARE (IM) </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2010-07-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms060878">CMS R-285</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Request for Retirement Benefit Information </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2023-02-28 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms009548">CMS R-296</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> HOME HEALTH ADVANCE BENEFICIARY NOTICE </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2009-08-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms10396">CMS-10396</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Medication Therapy Management Program Standardize Format </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2012-01-20 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms10455">CMS-10455</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Report of a Hospital Death Associated with Restraint or Seclusion </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2018-07-19 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-list/cms10797">CMS-10797</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances) </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2022-04-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms054015">CMS-R-0235 D1</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> DSH Data Use Agreement for Cost Reporting Periods Prior to those that include December 8, 2004 </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2009-12-01 </div> </td> </tr> <tr> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form #</label> <a href="/medicare/cms-forms/cms-forms/cms-forms-items/cms055728">CMS-R-0235 D2</a> </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Form Title</label> DSH Data Use Agreement for Cost Reporting Periods that Include December 8, 2004 and therafter </div> </td> <td><div class="js-form-item form-item js-form-type-item form-item- js-form-item- form-no-label"> <label class="ds-c-label visually-hidden">Revision Date</label> 2009-12-01 </div> </td> </tr> </tbody> </table> </div> <div class="ds-u-margin-y--1"> <a href="/rss/31831" class="feed-icon dynamic-list-rss"> <span 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