CMS Forms

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CMS Forms List

The following provides access and/or information for many CMS forms. You may also use the "Search" feature to more quickly locate information for a specific form number or form title.

Form # Form Title Revision Date
CMS 40F APPLICATION FOR ENROLLMENT IN MEDICAL INS UNDER MEDICARE 11/01/1981
CMS L457 ACKNOWLEDGMENT OF REQUEST FOR MEDICARE MEDICAL INSURANCE TERMINATION 02/01/2003
CMS L458 ACKNOWLEDGMENT OF REQUEST FOR PREMIUM HOSPITAL INSURANCE TERMINATION 02/01/2003
CMS 1592 SMI PREMIUM ACCTG FORM 07/01/1986
CMS 1960 REQUEST FOR EVIDENCE OF MEDICAL NECESSITY 05/01/1969
CMS 2384 THIRD PARTY PREMIUM BILLING REQUEST, MEDICARE 11/01/2003
CMS 2690 REQ FOR CANCELLATION OF SMI 03/01/1978
HCFA 378E AMBULATORY SURGICAL CTR REPORT--CRUCIAL DATA EXTRACT N/A
CMS 820 IN-CENTER HEMODIALYSIS (HD) CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2005 01/01/2005
CMS 821 PERITONEAL DIALYSIS CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2005 01/01/2005
CMS 10055 SKILLED NURSING FACILITY ADVANCED BENEFICIARY NOTICE N/A
CMS 20007 NOTICE OF EXCLUSIONS FROM MEDICARE BENEFITS (NEMB) 01/01/2003
CMS 20014 NOTICE OF EXCLUSIONS FROM MEDICARE BENEFITS - SKILLED NURSING FACILITY (NEMB-SNF) N/A
CMS 5011A-B REQUEST FOR MEDICARE HEARING BY ADMINISTRATIVE LAW JUDGE 08/01/2005
CMS 20027 MEDICARE REDETERMINATION REQUEST FORM 12/29/2010
CMS 20031 TRANSFER (ASSIGNMENT) OF APPEAL RIGHTS 05/01/2005
CMS 20033 MEDICARE RECONSIDERATION REQUEST FORM 12/29/2010
CMS 20034A/B REQUEST FOR MEDICARE HEARING BY AN ADMINISTRATIVE LAW JUDGE 08/01/2005
CMS 2628 (35 KB) Foreign HI Claim or Emergency Services Accessibility Documentation and Determination 05/01/1986
CMS 636 TRANSMITTAL NOTICE HEARING CASE 06/01/1988
CMS 20040 Regional Office Meeting/Speaker Request Form 12/01/05
CMS 20041 Speech Invitation Request Background Information 12/01/05
CMS 500 NOTICE OF MEDICARE PREMIUM PAYMENT DUE (English / Spanish) 01/01/2003
CMS 339 PROVIDER COST REPORT REIMBURSEMENT QUESTIONNAIRE 04//30/2006
CMS 416 Early ad Periodic Screening Diagnostic and Treatment Participation Report 06/1999
CMS 2178 HI/SMI ENTITLEMENT PROBLEM REFERRAL 09/01/2006
CMS 2802 REQUEST FOR VALIDATION OF ACCREDITATION 02/01/2011
CMS 2802B REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR HOSPICE 02/01/2011
CMS 2802C REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR HOME HEALTH AGENCY 02/01/2011
CMS 2802D REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR AMBULATORY SURGICAL CENTER 02/01/2011
CMS 1771 ATTENDING PHYSICIANS STATEMENT AND DOCUMENTATION FOR MEDICARE EMERGENCY 09/01/1977
CMS 2552-96 COST REPORT FOR ELECTRONIC FILING OF HOSPITALS 05/01/2004
CMS 216 ORGAN PROCUREMENT ORGANIZATION-HISTO-COMPATIBILITY LAB STATEMENT OF REIMBURSABLE COSTS 11/01/2005
CMS 222 INDEPENDENT RURAL HEALTH CLINIC WORKSHEET 01/01/2005
CMS 287 HOME OFFICE COST STATEMENT 11/01/1995
CMS 378 AMBULATORY SURGICAL CENTER SURVEY REPORT 01/01/1997
CMS 484 CERTIFICATE OF MEDICAL NECESSITY - Oxygen DME 484.03 09/30/2005
CMS 562 Medicare/Medicaid/CLIA Complaint Form 01/01/1993
CMS 576 Organ Procurement Request for Designation as an OPO 01/01/1993
CMS 576A Health Insurance Benefits Agreement with Organ Procurement Organization 06/29/2006
CMS 671 LTC Facility Application for Medicare/Medicaid 12/01/2002
CMS 3509 ALJ MEDICARE CASE FOLDER (CMS) 08/02/2002
CMS 2007 PROVIDER TIE IN NOTICE 03/01/1982
CMS 384 QIO CASE SUMMARY 03/01/1992
CMS 2501 RECONSIDERATION DETERMINATION 01/01/1972
CMS 2567B POST-CERTIFICATION REVISIT REPORT 09/01/1992
CMS 383 HEALTH INSURANCE CASE SUMMARY 12/01/1982
CMS 2878 ACCREDITED HOSPITAL ALLEGATIONS REPORT 04/01/1986
CMS 1539 MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL 07/01/1984
CMS 360 CORF SURVEY REPORT 12/01/2008
CMS 359 CORF REPORT FOR CERTIFICATION TO PARTICIPATE IN MEDICARE 07/01/2003
CMS 353 PART A PREHEARING INPUT RECORD 06/01/1986
CMS 352 PART A RECONSIDERATION INPUT RECORD 06/01/1986
CMS 36P CONSENT FOR HOME VISIT FOR PACE SERVICES EVALUATION 07/01/2002
CMS 36 CONSENT FOR HOME VISIT (English/Spanish) 12/01/1990
CMS 1563 Monthly Intermediary Report on Medicare Secondary Payer Savings 11/01/1997
CMS 462L ADVERSE ACTI0N EXTRACT FOR SNFs AND NFs 07/01/1995
CMS 673 Extended/Partial Extended Survey Worksheet 07/01/1995
CMS 701 Updated Plan of Progress for Outpatient Rehab 11/01/1991
CMS 1980 CARRIER OR INTERMEDIARY REQUEST FOR SSO ASSISTANCE 03/01/1978
CMS 801 Offsite Survey Prep Worksheet 07/01/1995
CMS 804 Kitchen/Food Service Observation 07/01/1995
CMS 1880 REQUEST FOR CERTIFICATION AS SUPPLIER OF PORTABLE XRAY SERVICES 10/01/1980
CMS 1557 SURVEY REPORT FORM - CLIA 09/01/1992
CMS 462AB CLIA ADVERSE ACTION EXTRACT 05/01/1997
CMS 806B Quality of Life Assessment--Group 07/01/1995
CMS 803 General Observations of Facility 07/01/1995
CMS 838 Medicare Credit Balance Reporting Requirements 10/01/2003
CMS 677 Medication Pass Worksheet 07/01/1995
CMS 1965 REQUEST FOR HEARING - PART B MEDICARE CLAIM 05/01/2003
CMS 700 Plan of Treatment for Outpatient Rehab 11/01/1991
CMS 806A Quality of Life Assessment--Resident 07/01/1995
CMS 1564 MONTHLY CARRIER REPORT ON MEDICARE SECONDARY PAYER SAVINGS 11/01/1997
CMS 1666 REGIONAL OFFICE REQUEST FOR ADDITIONAL INFORMATION 04/01/1980
CMS 10106 1-800-Medicare Authorization to Disclosure Personal Health Information 04/01/2008
CMS 806C Quality of Life Assessment--Family 07/01/1995
CMS 807 Surveyor Notes Worksheet 07/01/1995
CMS 4040 REQUEST FOR ENROLLMENT IN SUPPLEMENTARY MEDICAL INSURANCE (English / Spanish) 08/01/1991
CMS 1541B RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN EMERGENCY CASES INVESTIGATION REPORT 04/01/1995
CMS 802S Roster/Sample Matrix Instruction for Surveyors 10/01/2010
CMS 802P Roster/Sample Matrix Provider Instructions 10/01/2010
CMS 802 Roster/Sample Matrix 10/01/2010
CMS 805 Resident Review Worksheet 10/01/2010
CMS 672 Resident Census and Conditions of Residents 10/01/2010
CMS 40B APPLICATION FOR ENROLLMENT IN MEDICARE 01/01/1990
CMS R-193 IMPORTANT MESSAGE FROM MEDICARE (IM) 10/01/2007
CMS 1728 HOME HEALTH AGENCY COST REPORT 06/01/2001
CMS 179 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL 07/01/1992
CMS 43 APPLICATION FOR HEALTH INSURANCE UNDER MEDICARE FOR INDIVIDUAL WITH CHRONIC RENAL DISEASE 08/01/1981
CMS 10114 NATIONAL PROVIDER IDENTIFIER (NPI) APPLICATION/UPDATE FORM 11/01/2008
CMS 10252 DATA USE AGREEMENT (DUA) CERTFICATE OF DISPOSITION (COD) FOR DATA ACQUIRED FROM THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) 05/29/2012
CMS 116 CLINICAL LABORATORY IMPROVEMENT AMENDMENTS OF 1988 (CLIA) APPLICATION FOR CERTIFICATION 10/01/2010
CMS 18F APPLICATION FOR HOSPITAL INSURANCE (English / Spanish) 02/01/1991
CMS R-131 ADVANCE BENEFICIARY NOTICE (ABN) 06/01/2002
CMS 265 INDEPENDENT RENAL DIALYSIS FACILITY COST REPORT 03/01/2005
CMS 417 HOSPICE REQUEST FOR CERTIFICATION IN MEDICARE 08/01/2010
CMS 724 Medicare/Medicaid Psychiatric Hospital Survey Data 09/01/1994
CMS 725 Surveyor Worksheet for Psychiatric Hospital Review:Two Special Conditions 09/01/1994
CMS 726 CMS Death Record Review Data Sheet 09/01/1994
CMS 727 CMS Nursing Complement Data 09/01/1994
CMS 728 CMS Staff Data 09/01/1994
CMS 729 Data Collection Medical Staff Coverage 09/01/1994
CMS 1561A HEALTH INSURANCE BENEFIT AGREEMENT-RURAL HEALTH CLINIC 04/01/2002
CMS 1561 HEALTH INSURANCE BENEFIT AGREEMENT 07/01/2001
CMS 1984 HOSPICE COST REPORT 02/01/2005
CMS 2088-92 OUTPATIENT REHAB PROVIDER COST REPORT 12/01/2004
CMS 1696 APPOINTMENT OF REPRESENTATIVE 06/01/2012
CMS 643 (28 KB) Hospice Survey AND Deficiencies Report 06/01/2008
CMS R-285 Request for Retirement Benefit Information 03/01/2006
CMS 1882 PORTABLE XRAY SURVEY REPORT 02/01/2009
CMS 588 Electronic Funds Transfer (EFT) Authorization Agreement 05/01/2010
CMS 10221 Independent Diagnostic Testing Facilities-Site Investigation 08/01/2012
CMS 460 MEDICARE PARTICIPATING PHYSICIAN OR SUPPLIER AGREEMENT 04/01/2010
CMS 1500 Health Insurance Claim Form 08/01/2005
CMS 379 FINANCIAL STATEMENT OF DEBTOR 07/01/2007
CMS 29 REQUEST TO ESTABLISH ELIGIBILITY TO PARTICIPATE IN HI FOR AGED/DISABLED TO PROVIDE RURAL HEALTH CLINIC SERVICES 05/01/1978
CMS 2786X REPORT - ICF/MR APARTMENT HOUSE - 2000 CODE 06/01/2007
CMS 2786Y FIRE SAFETY SURVEY REPORT ICF/MR - SMALL FSES - 2000 CODE 06/01/2007
CMS 2786U FIRE SAFETY SURVEY REPORT - AMBULATORY SURGICAL CENTERS - MEDICARE - 2000 CODE 10/01/2008
CMS 2786T FIRE/SMOKE ZONE EVALUATION WORKSHEET FOR HEALTH CARE FACILITIES - 2000 CODE 06/01/2007
CMS 2786S FIRE SAFETY SURVEY REPORT SHORT FORM - MEDICARE - MEDICAID 06/01/2007
CMS 2786R FIRE SAFETY SURVEY REPORT 2000 CODE - HEALTH CARE - MEDICARE - MEDICAID 06/01/2007
CMS 2786W FIRE SAFETY SURVEY REPORT - ICF/MR - LARGE FACILITIES - 2000 CODE 06/01/2007
CMS 2786V FIRE SAFETY SURVEY REPORT ICF/MR - SMALL FACILITIES - 2000 CODE 06/01/2007
CMS 2786M FIRE SAFETY SURVEY - RATING RESIDENTS - 2000 CODE 03/01/2004
CMS 3070I INDIVIDUAL OBSERVATION WORKSHEET 10/01/1995
CMS 3070H ICF/MR DEFICIENCIES REPORT 11/01/2000
CMS 3070G ICF/MR SURVEY REPORT 03/01/2001
CMS L564 Medicare Information 08/31/2013
CMS 10269 CMN Positive Airway Pressure (PAP)Devices for Obstructive Sleep Apnea 12/01/2009
CMS 2567 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION 02/01/1999
CMS 20042 Section 1011 Dispute Resolution Request 11/01/2010
CMS 10115 SECTION 1011 PROVIDER ENROLLMENT APPLICATION 04/01/2012
CMS 20017 ADVISORY PANEL ON HOSPITAL OUTPATIENT PAYMENT 07/01/2012
CMS 370 HEALTH INSURANCE BENEFITS AGREEMENT-AMBULATORY SURGICAL CENTER 04/01/2002
CMS 377 AMBULATORY SURGICAL CENTER REQUEST FOR CERTIFICATION IN MEDICARE 12/01/2010
CMS 2802E REQUEST FOR VALIDATION OF ACCREDITATION FOR CRITICAL ACCESS HOSPITAL SURVEY 02/01/2011
CMS 10036 Inpatient Rehabilitation Facility-Patient Assessment Instrument 01/01/06
CMS 10125 DME Information Form - External Infusion Pumps DME 09.03 09/30/2005
CMS 10126 DME Information Form - Enteral and Parenteral Nutrition DME 10.03 09/30/2005
CMS 847 Certificate of Medical Necessity - Osteogenesis Stimulators - DME 04.04C 09/30/2005
CMS 849 Certificate of Medical Necessity - Seat Lift Mechanisms - DME 07.03A 09/30/2005
CMS 854 Certificate of Medical Necessity - DME 11.02 09/30/2005
CMS 848 Certificate of Medical Necessity - Transcutaneous Electrical Nerve Stimulator (TENS) - DME 06.03B 09/30/2005
CMS 846 Certificate of Medical Necessity - Pneumatic Compression Devices DME 04.04B 09/30/2005
CMS 10156 Retiree Drug Subsidy 08/01/2005
CMS 10198 Creditable Coverage Disclosure to CMS On-line Form and Instructions 02/01/2007
CMS 437 PSYCHIATRIC UNIT CRITERIA WORKSHEET 04/01/2006
CMS 1763 REQ FOR TERMINATION OF PREMIUM HI/SMI 05/01/1997
CMS 1957 SSO REPORT OF STATE BUY IN PROBLEM 03/01/1994
CMS 2540-96 SNF AND SNF HEALTH CARE COMPLEX COST REPORT 05/01/2006
CMS 1490S PATIENT'S REQUEST FOR MEDICAL PAYMENT (English/Spanish) 01/01/2005
CMS 10003-NDP NOTICE OF DENIAL OF PAYMENT 01/01/2007
CMS 10003NDMC NOTICE OF DENIAL OF MEDICAL COVERAGE 01/01/2007
CMS 632FOI FREEDOM OF INFORMATION ACT REQUEST 01/01/2008
CMS 633 Invoice of Fees for FOIA Services 01/01/2008
CMS 1450 UB-04 Uniform Bill 03/01/2007
CMS 209 LABORATORY PERSONNEL REPORT (CLIA) 09/01/1992
CMS 10095NOMNC NOTICE OF MEDICARE NON-COVERAGE 12/01/2006
CMS 855A Medicare Enrollment Application - Institutional Providers 07/01/2011
CMS 855B Medicare Enrollment Application - Clinics/Group Practices and Certain Other Suppliers 07/01/2011
CMS 855I Medicare Enrollment Application - Physicians and Non-Physician Practitioners 07/01/2011
CMS 855O Medicare Enrollment Application - For Eligible Ordering and Referring Physicians and Non-Physician Practitioners 08/01/2012
CMS 10069 Medicare Waiver Demonstration Application 12/01/2010
CMS 855R Medicare Enrollment Application - Reassignment of Medicare Benefits 07/01/2011
CMS 855S Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers 07/01/2011
CMS 10287 Medicare Quality of Care Complaint Form 09/01/2010
CMS 668B Post Lab Survey - CLIA 01/01/2012
CMS 10095DENC Detailed Explanation of Non-Coverage 12/01/2006
CMS 2802F Authorization for State Agency Psychiatric Hospital Validation Survey 11/01/2011
CMS 437B REHAB HOSPITAL CRITERIA WORKSHEET 06/01/2012
CMS 437A REHAB UNIT CRITERIA WORKSHEET 06/01/2012
CMS 10175 Electronic File Interchange Organization (EFIO) Certification Statement 08/01/2006
CMS 10164 Centers for Medicare and Medicaid Services EDI Registration Form; and EDI Enrollment Form 03/01/2006
CMS 10130B Request for Section 1011 Hospital On-Call Payments to Physicians 05/01/2005
CMS 10130A Section 1011 Provider Payment Determination 01/01/2006
CMS R-296 HOME HEALTH ADVANCE BENEFICIARY NOTICE 08/01/2009
CMS 2744B END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM ESRD FACILITY SURVEY (TRANSPLANT CENTERS ONLY) 02/01/2004
CMS 2744A ESRD FACILITY SURVEY (DIALYSIS UNIT ONLY) 02/01/2004
CMS 1515A HHA Functional Assessment Instrumental: Module A 12/01/2005
CMS 1515B HOME HEALTH FUNCTIONAL ASSESSMENT INSTRUMENT: MODULE B 06/01/1990
CMS 1515C HOME HEALTH FUNCTIONAL ASSESSMENT MODULE C: HOME VISIT 06/01/1990
CMS 1515D HOME HEALTH FUNCTIONAL ASSESSMENT PATIENT CARE: MODULE D 06/01/1990
CMS 1515E HOME HEALTH FUNCTION AND CARE SUMMARY: MODULE E 06/01/1990
CMS 1515F CALENDAR WORKSHEET - PRESCRIBED VISITS 06/01/1990
CMS 1572A HHA SURVEY AND DEFICIENCIES REPORT 08/01/1990
CMS 10146 Notice of Denial of Medicare Prescription Drug Coverage English/Spanish 01/01/2011
CMS 2728 ESRD MEDICAL EVIDENCE REPORT MEDICARE ENTITLEMENT AND/OR PATIENT REGISTRATION 03/01/2006
CMS 10123 EXPEDITED REVIEW NOTICE-NOTICE OF MEDICARE PROVIDER NON-COVERAGE 02/29/2008
CMS 10124 EXPEDITED REVIEW NOTICE-DETAILED EXPLANATION OF NON-COVERAGE 02/29/2008
CMS R-0235L (64 KB) Data Use Agreement (DUA)- Limited Data Sets 02/01/2008
CMS R-0235U (48 KB) Data Use Agreement (DUA)- Update to Existing DUA 01/01/2010
CMS R-0235 (66 KB) Data Use Agreement (DUA) (Agreement for use of Centers for Medicare and Medicaid Services (CMS) data containing individual-specific information 06/01/2010
CMS R-0235ST State Data Use Agreement 03/01/2006
CMS R-0235MC Compliance Plan for Accounting for Disclosures of Privacy Protected Data Released From a System of Records (SOR) Housed in a State-Located Server 03/01/2006
CMS R-0235M Medicaid Agency Data Use Agreement 07/01/2007
CMS R-0235A (35 KB) Addendum to Data Use Agreement (DUA) 03/01/2006
CMS R-0235MA Addendum to the Medicaid State Agency Data Use Agreement 03/01/2006
CMS 381 MODEL LETTER REQUESTING IDENTIFICATION OF EXTENSION LOCATIONS 12/01/2005
CMS 1856 Request for Certification in the Medicare and/or Medicaid Program to Provide Outpatient Physical Therapy and/or Speech Pathology Services 12/11/2006
CMS 1893 OUTPATIENT PHYSICAL THERAPY - SPEECH PATHOLOGY SURVEY REPORT 12/01/2008
CMS 2746 ESRD DEATH NOTIFICATION 08/01/2006
CMS-R-0235 D1 DSH Data Use Agreement for Cost Reporting Periods Prior to those that include December 8, 2004 2009-12-01
CMS-R-0235 D2 DSH Data Use Agreement for Cost Reporting Periods that Include December 8, 2004 and therafter 2009-12-01
CMS-10396 Medication Therapy Management Program Standardize Format 2012-01-20