Enrollment Forms - JE Part B
- Provider Enrollment CAP Reconsideration Coversheets
- CMS Provider Enrollment CAP Reconsideration Coversheet [PDF] - Choose this form if your letter said to send to CMS
- Noridian Provider Enrollment CAP Reconsideration Coversheet [PDF] - 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 855R - Reassignment of Benefits
- CMS 8550 - 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
- Laboratories Billing for Referred Tests - Self Attestation [PDF]
- Opt Out - Affidavit [PDF]
- Opt Out - Private Contract [PDF]
- Rebuttal Coversheet [PDF]
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.
Last Updated Thu, 25 Oct 2018 12:52:21 +0000