Advance Beneficiary Notice of Noncoverage (ABN) Forms

Appeals Forms

General Written Inquiries Forms

Other Review Contractor Forms

Universal

Comprehensive Error Rate Testing (CERT)

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

Publication Order Form

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

Assistant Superintendent
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 This link will take you to an external website. for general form completion instructions.

Submit paper claims to appropriate state address indicated on Mailing Addresses webpage.

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.

Last Updated Oct 25, 2018