Forms - JF 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 14:00:24 +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
- Admission Questions to Ask Medicare Beneficiaries [PDF]
- MSP [PDF] Newly revised February 2023
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.
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Last Updated Thu, 25 Oct 2018 12:52:21 +0000