Forms - JE Part B
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
- CMS-1500 Claim Form
- Educational
- Enrollment
- Freedom of Information Act (FOIA)
- General Written Inquiries
- Medical Review
- Medicare Secondary Payer (MSP)
- Other Review Contractors
- Overpayment / Recoupment
- Patient Screening
- Policies
- Professional Provider Telecommunications Network (PPTN)
- Publication Order Forms
- Roster Mass Immunizers Claims (COVID-19, Influenza & Pneumonia)
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
Appeals Forms
- 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 [PDF]
- Reopening [PDF]
CMS-1500 Claim Form
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
Educational Forms
Enrollment Forms
- 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 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]
Freedom of Information Act (FOIA) Form
General Written Inquiry Forms
Medicare Secondary Payer (MSP) Forms
- Admission Questions to Ask Medicare Beneficiaries [PDF]
- MSP [PDF] Newly revised March 2024.
- MSP Voluntary Checks [PDF]
- MSP Voluntary Refund Spreadsheet [Excel]
Other Review Contractor Forms
Universal
- 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]
- ERS Amortization Schedule [Excel]
- Extended Repayment Schedule (ERS) Request [PDF]
- Immediate Recoupment [PDF]
- MSP Voluntary Checks [PDF]
- MSP Voluntary Refund Spreadsheet [Excel]
- Non-MSP Voluntary Checks [PDF]
- Non-MSP Voluntary Refund Spreadsheet [Excel]
Patient Screening Forms
Professional Provider Telecommunications Network (PPTN) Form
Publication Order Forms
- MPFS Purchase [PDF]
- Jurisdiction E Bulletin Subscription [PDF]
Roster Mass Immunizers Claims (COVID-19, Influenza & Pneumonia)
Form Assistance
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.
If this error continues, it may be necessary to update your version of Adobe Reader, or to disable the option to display PDFs in your browser. See Display PDF in browser help webpage.
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.