Enrollment Forms - JF Part A
- Attachment B - Community Mental Health Center Site Visit Request [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)
- Supplemental Facility-Based/Fiscal Year Request Statement [PDF]
- Supplemental Facility-Based/Fiscal Year Request Statement Instructions
- 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