Forms - JA DME
Forms
Access common Medicare forms and view tips for downloading and completing interactive forms below. See all CMS forms on the CMS Forms page.
- Advance Beneficiary Notice of Noncoverage (ABN)
- Appeals
- Certificates of Medical Necessity (CMNs)
and DME Information Forms (DIFs) - CMS-1500 Claim Form
- Educational
- Enrollment
- Freedom of Information Act (FOIA)
- Medicare Secondary Payer (MSP)
- Miscellaneous
- Pre-Claim Review
- Refunds/Overpayments
- Reopening
- User Provisioning (Claim Status Inquiry Support)
Correspondence may be sent via fax, esMD, mail, or via CD, DVD, or USB. See the Options for Submitting Documentation page for more information.
Advance Beneficiary Notice of Noncoverage (ABN) Forms
Appeal Forms
General
- CMS-1696
- Appointment of Representative
- CMS 20031
- Documentation Checklists
Redetermination - (First level)
- CMS 20027
- Medicare DME Redetermination Request [PDF]
Reconsideration - (Second level)
- CMS 20033
Administrative Law Judge (ALJ) Hearing - (Third level)
Medicare Appeals Council Review (Departmental Appeals Board (DAB)) - (Fourth level)
Certificate of Medical Necessity (CMN) and DME Information Form (DIF) Forms
(Required for dates of service prior to January 1, 2023 only)
- CMS 484
- Oxygen
- CMS 846
- CMS 847
- CMS 848
- CMS 849
- CMS 854
- CMS 10125
- CMS 10126
CMS-1500 Claim Form
This form is the prescribed form for claims prepared and submitted by physicians or suppliers. It can be purchased in any version required by calling the U.S. Government Printing Office at 202-512-1800.
Freedom of Information Act (FOIA) Form
Medicare Secondary Payer (MSP) Forms
- MSP Overpayment Refund Form [PDF] - Refund related to MSP claim
- MSP Overpayment Refund Spreadsheet [Excel] - Subsequent attachment to above form
- Medicare Secondary Payer [PDF]
- Medicare Secondary Payer Questionnaire [PDF] - Use to facilitate identification and proper billing of MSP cases. Beneficiary or registration personnel may complete
Miscellaneous Forms
- Paperwork (PWK) Fax/Mail Coversheet [PDF]
- Review Contractor Correspondence Tracking [Excel]
- Signature Attestation Statement [PDF]
- Suggested Intake [PDF]
Comprehensive Error Rate Testing (CERT)
- Provider CERT POC [PDF]
Pre-Claim Review Forms
Refunds/Overpayments Forms
- Accelerated and Advance Payment Form [PDF]
- CAAP Debt Dispute Form [PDF]
- CMS 379
- ERS Amortization Schedule [Excel]
- Extended Repayment Schedule (ERS) Request [PDF]
- Immediate Recoupment/Offset [PDF] - When requesting immediate recoupment before automatic offset
- MSP Overpayment Refund Form [PDF] - Refund related to Medicare Secondary Payer (MSP) claim
- MSP Overpayment Refund Spreadsheet [Excel] - Subsequent attachment to above form for multiple requests
- Non-MSP Voluntary Refund Checks Form [PDF] - Submit a refund not related to MSP - use when enclosing a check
- Non-MSP Overpayment Refund Spreadsheet [Excel] - Subsequent attachment to above form for multiple requests
- Instructions Non-MSP Overpayment Refund Request - to submit an overpayment request not related to MSP - use when not enclosing a check
Reopening Form
User Provisioning (Claim Status Inquiry Support) Form
Form Assistance
PDF File Downloading Technical Assistance
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Interactive Form Tips
Select "Highlight fields" and/or "Highlight required fields" to ensure all form fields are completed.
To view field instructions (including CMS supplied instructions, when provided), hover over desired field.
Blank and completed forms may be saved to a user's computer. Right-click PDF hyperlink and select "Save as."
Electronic completion minimizes possibility of illegible handwritten forms.
