Enrollment Forms - JF Part B
Enrollment Forms
- Noridian Provider Enrollment CAP Reconsideration Coversheet - 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 855O - 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
- CMS 370 - Ambulatory Surgical Center Health Insurance Benefits Agreement
- Laboratories Billing for Referred Tests - Self Attestation
- Opt Out - Affidavit
- Opt Out - Private Contract
- Rebuttal Coversheet
Se ha producido un error al procesar la plantilla.
Java method "com.liferay.portal.kernel.util.DateUtil_IW.parseDate(String, String, Locale)" threw an exception when invoked on com.liferay.portal.kernel.util.DateUtil_IW object "com.liferay.portal.kernel.util.DateUtil_IW@66eb0c42"; see cause exception in the Java stack trace.
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FTL stack trace ("~" means nesting-related):
- Failed at: #assign norModifieddateObj = dateUtil... [in template "medicare-velocity-templates-theme_SERVLET_CONTEXT_/templates/freemarker/content/free-form-text.ftl" at line 11, column 5]
- Reached through: #include "medicare-velocity-templates... [in template "10155#10193#74691" at line 1, column 1]
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1<#include "medicare-velocity-templates-theme_SERVLET_CONTEXT_/templates/freemarker/content/free-form-text.ftl">
