• 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

This form is the prescribed form for claims prepared and submitted by physicians or suppliers, whether or not the claims are assigned. It can be purchased in any version required by calling the U.S. Government Printing Office at 202-512-1800

• CMS-1500 Claim Form Instructions
• CMS-1500 Claim Form Tutorial

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

• Noridian Provider Enrollment CAP Reconsideration Coversheet - Choose this form if your letter said to send to Noridian
• CMS 460 - Medicare Participating Physician or Supplier Agreement
• CMS 588 - Authorization Agreement for Electronic Funds Transfer (EFT)
• CMS 855B - Clinics, Group Practices, and Certain Other Suppliers
• CMS 855I - Individual Practitioners
• CMS 855O - Eligible Ordering, Certifying and Prescribing Physicians, and Other Eligible Professionals
• CMS 20134 - Medicare Diabetes Prevention Program (MDPP) Suppliers
• CMS 1561 - OTP Health Insurance Benefit Agreement
• CMS 370 - Ambulatory Surgical Center Health Insurance Benefits Agreement
• Laboratories Billing for Referred Tests - Self Attestation
• Opt Out - Affidavit
• Opt Out - Private Contract
• Rebuttal Coversheet

• Freedom of Information Act (FOIA) Request

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

• Authorization to Speak to an Outside Entity
• Documentation Requirement Checklists
• Part B ASC Prior Authorization Request Coversheet
• Prior Authorization Request for Repetitive, Scheduled Non-Emergent Ambulance Transports Medicare Part B Fax/Mail Coversheet
• PWK Coversheet
• Signature Attestation Statement
• WISeR Prior Authorization Request Coversheet

• Admission Questions to Ask Medicare Beneficiaries
• MSP Newly revised November 2025.
• MSP Voluntary Checks
• MSP Voluntary Refund Spreadsheet

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

• Accelerated and Advance Payment Form
• ERS Amortization Schedule
• Extended Repayment Schedule (ERS) Request
• Immediate Recoupment
• MSP Voluntary Checks
• MSP Voluntary Refund Spreadsheet
• Non-MSP Voluntary Checks
• Non-MSP Voluntary Refund Spreadsheet

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

• MPFS Purchase

• Hepatitis B Vaccine Roster Form
• Influenza (Flu) Vaccine Roster
• Pneumococcal Pneumonia Vaccine (PPV) Roster