Forms - JE Part A
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)
- Audit and Reimbursement
- Direct Data Entry (DDE)
- Freedom of Information Act (FOIA)
- General Written Inquiries
- Medical Review
- Medicare Secondary Payer (MSP)
- Other Review Contractors
- Overpayment / Recoupment
- Publication Order Form
- Roster Mass Immunizers Claims (COVID-19, Influenza & Pneumonia)
- UB-04 (CMS-1450)
Last Updated Tue, 22 Jun 2021 13:10:59 +0000
- CMS 1696 - Appointment of Representative
- 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 [PDF]
Audit and Reimbursement 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 588 EFT Instructions
- CMS 855A - Institutional Providers
- CMS 855A 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 [PDF]
- Supplemental Facility-Based/Fiscal Year Request Statement [PDF]
- Supplemental Facility-Based/Fiscal Year Request Statement Instructions
General Written Inquiry Forms
Medical Review Forms
Other Review Contractor Forms
- Documentation Requirement Checklists
- Electronic Order Signature Process [PDF]
- Review Contractor Correspondence Tracking [Excel]
- Signature Attestation Statement [PDF]
Comprehensive Error Rate Testing (CERT)
- Provider CERT POC [PDF]
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
Overpayment / Recoupment Forms
- Accelerated and Advance Payment Form [PDF]
- CAAP Debt Dispute Form [PDF]
- Credit Balance Report: CMS 838 Form and Instructions or Noridian 838 Form [Excel]
- ERS Amortization Schedule [Excel]
- Extended Repayment Schedule (ERS) Request [PDF]
- Immediate Offset Request [PDF]
- Voluntary Checks Form - MSP [PDF]
- Voluntary Checks Form - Non-MSP [PDF]
Roster Mass Immunizers Claims (COVID-19, Influenza & Pneumonia)
UB-04 (CMS-1450) Form
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
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.
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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.
Last Updated Thu, 25 Oct 2018 12:52:21 +0000