Enrollment Forms - JE Part A
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Enrollment Forms
- Attachment B - Community Mental Health Center Site Visit Request [PDF]
- Provider Enrollment CAP Reconsideration Coversheet [PDF]
- CMS 588
- Authorization Agreement for Electronic Funds Transfer (EFT)
- CMS 855A
- CMS Exhibit 178 and 177 - Federally Qualified Health Centers (FQHCs)
- CMS Exhibit 275 - Attestation Statement for Community Mental Health Centers (CMHCs)
- CMS Exhibit 282 - Community Mental Health Centers
- CMS Provider-Based Status Attestation Statement (sample)
- Rebuttal Coversheet [PDF]
- Supplemental Facility-Based/Fiscal Year Request Statement [PDF]
- Supplemental Facility-Based/Fiscal Year Request Statement Instructions
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