• ABN - CMS-R-131
• Instructions
• Tutorial

• CMS 1696 - Appointment of Representative
  • Appointment of Representative Form Instructions
  • Appointment of Representative Form Tutorial
• CMS 20031 - Transfer (Assignment) of Appeal Rights
• CMS 20033 - Medicare Reconsideration Request
• DAB-101 - Request for Review of an Administrative Law Judge (ALJ) Medicare Decision / Dismissal
• Documentation Requirement Checklists
• OMHA-100 & OMHA-100A Forms - Request for Medicare Hearing by an ALJ
• Redetermination/Reopening
  • Redetermination/Reopening Form Instructions
  • Redetermination/Reopening Form Tutorial

• Certified Registered Nurse Anesthetist (CRNA) Exemption Request
• Cost Report Extension Form
• Cost Report Forms
• Inpatient Rehabilitation Facility (IRF) Self-Attestation
• Provider Audit Media Submission Form
• Provider-Based Designation Checklist
• Rural Health Clinic (RHC) Productivity Standard Exception Request
• RHC and FQHC COVID-19 Vaccine Lump Sum Request Form
• Volume Decrease Adjustment (VDA) Checklist

• Medicare Claims Processing System DDE/PPTN/CSI User Request

• ACM Provider Question Submission
• Individual Education Request
• POE Advisory Group Membership Application
• Speaker Request

• Attachment B - Community Mental Health Center Site Visit Request
• Provider Enrollment CAP Reconsideration Coversheet
• CMS 588 - Authorization Agreement for Electronic Funds Transfer (EFT)
  • CMS 588 EFT Instructions
• CMS 855A - Institutional Providers
  • Skilled Nursing Facility Attachment Instructions
• 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
• Supplemental Facility-Based/Fiscal Year Request Statement
• Supplemental Facility-Based/Fiscal Year Request Statement Instructions

• Freedom of Information Act (FOIA) Request
• Freedom of Information Act Request Form for Audit and Reimbursement Records

• General Written Inquiries - Allow 45 business days for a written response. For faster service, we highly recommend contacting the Provider Contact Center.

• Electronic Order Signature Process
• Part A Prior Authorization Request Coversheet
• Part A Prior Authorization OPD Services Education Request Form
• PWK Coversheet
• Signature Attestation Statement
• WISeR Prior Authorization Request Coversheet

• Admission Questions to Ask Medicare Beneficiaries
• MSP Newly revised November 2025.

• CMS-10611 - MOON Form and Instructions

Universal

• Documentation Requirement Checklists
• Electronic Order Signature Process
• Review Contractor Correspondence Tracking
• Signature Attestation Statement

Comprehensive Error Rate Testing (CERT)

• Provider CERT POC

Recovery Auditor (RAC)

• There are no specific RAC related forms, see Universal forms

Supplemental Medical Review Contractor (SMRC)

• There are no specific SMRC related forms, see Universal forms

• FDA Approved Carotid PTA with Stent Post Market Studies and Post Market Extension Studies Pre-Approval Data Submission Request

The CMS-1450 form (UB-04) can be used by an institutional provider to bill a Medicare fiscal intermediary (FI) when a provider qualifies for a waiver from ASCA requirement for electronic submission of claims.

Original UB04 claim forms can be obtained from U.S. Government Printing Office

Assistant Superintendent
Department of Acct Rep Division
USGPO Room C-830
Washington, DC 20401

See CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 25 for general form completion instructions.

Submit paper claims to appropriate state address indicated on Mailing Addresses webpage.