Forms - JA DME
- Advance Beneficiary Notice of Noncoverage (ABN)
- Certificates of Medical Necessity (CMNs)
and DME Information Forms (DIFs)
- CMS-1500 Claim Form
- Freedom of Information Act (FOIA)
- Medicare Secondary Payer (MSP)
- Pre-Claim Review
- 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.
- CMS-1696 - Appointment of Representative
- CMS 20031 - Transfer (Assignment) of Appeal Rights
- Documentation Checklists
Redetermination - (First level)
- CMS 20027 - Medicare Redetermination Request
- Medicare DME Redetermination Request [PDF]
Reconsideration - (Second level)
- CMS 20033 - Medicare Reconsideration Request
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 - Pneumatic Compression Device
- CMS 847 - Osteogenesis Stimulators
- CMS 848 - Transcutaneous Electrical Nerve Stimulator (TENS)
- CMS 849 - Seat Lift Mechanisms
- CMS 854 - "Section C" Continuation Form
- CMS 10125 - External Infusion Pumps
- CMS 10126 - Enteral and Parenteral Nutrition
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
- Accelerated and Advance Payment Form [PDF]
- CAAP Debt Dispute Form [PDF]
- CMS 379 - Financial Statement of Debtor
- 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
PDF File Downloading Technical Assistance
Due to varying Internet Browsers and versions of Adobe, users may receive the error message, "Adobe PDF Document. There is a problem with Adobe Acrobat/Reader. If it is running, exit, and try again. (0:104)"
If this occurs, close the error message and use the browser "refresh" button, or press the F5 key, to reload the PDF.
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.