Friday, July 20, 2018

Sample legal forms and business documents

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Department of Health and Human Services (HHS)

Free Department of Health and Human Services forms

Form TitleCoverage
CMS 10036Inpatient Rehabilitation Facility-Patient Assessment Instrument All States
CMS 10055SKILLED NURSING FACILITY ADVANCED BENEFICIARY NOTICE All States
CMS 10069Medicare Waiver Demonstration Application All States
CMS 10114NATIONAL PROVIDER IDENTIFIER (NPI) APPLICATION/UPDATE FORM All States
CMS 10115SECTION 1011 PROVIDER ENROLLMENT APPLICATION All States
CMS 10125DME Information Form - External Infusion Pumps DME 09.03 All States
CMS 10126DME Information Form - Enteral and Parenteral Nutrition DME 10.03 All States
CMS 10130ASection 1011 Provider Payment Determination All States
CMS 10130BRequest for Section 1011 Hospital On-Call Payments to Physicians All States
CMS 10146Notice of Denial of Medicare Prescription Drug Coverage English/Spanish All States
CMS 10164Centers for Medicare and Medicaid Services EDI Registration Form; and EDI Enrollment Form All States
CMS 10175Electronic File Interchange Organization (EFIO) Certification Statement All States
CMS 10221Independent Diagnostic Testing Facilities-Site Investigation All States
CMS 10252Instructions for Completing the Certificate of Data Destruction for Data Acquired from the Centers for Medicare & Medicaid Services All States
CMS 10269CMN Positive Airway Pressure (PAP)Devices for Obstructive Sleep Apnea All States
CMS 10287Medicare Quality of Care Complaint Form All States
CMS 116CLINICAL LABORATORY IMPROVEMENT AMENDMENTS OF 1988 (CLIA) APPLICATION FOR CERTIFICATION All States
CMS 1490SPATIENT'S REQUEST FOR MEDICAL PAYMENT (English/Spanish) All States
CMS 1500Health Insurance Claim Form All States
CMS 1515AHHA Functional Assessment Instrumental: Module A All States
CMS 1515BHOME HEALTH FUNCTIONAL ASSESSMENT INSTRUMENT: MODULE B All States
CMS 1515CHOME HEALTH FUNCTIONAL ASSESSMENT MODULE C: HOME VISIT All States
CMS 1515DHOME HEALTH FUNCTIONAL ASSESSMENT PATIENT CARE: MODULE D All States
CMS 1515EHOME HEALTH FUNCTION AND CARE SUMMARY: MODULE E All States
CMS 1515FCALENDAR WORKSHEET - PRESCRIBED VISITS All States
CMS 1539MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL All States
CMS 1541ARESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN EMERGENCY CASES All States
CMS 1541BRESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN EMERGENCY CASES INVESTIGATION REPORT All States
CMS 1557SURVEY REPORT FORM - CLIA All States
CMS 1561AHEALTH INSURANCE BENEFIT AGREEMENT-RURAL HEALTH CLINIC All States
CMS 1561HEALTH INSURANCE BENEFIT AGREEMENT All States
CMS 1563Monthly Intermediary Report on Medicare Secondary Payer Savings All States
CMS 1564MONTHLY CARRIER REPORT ON MEDICARE SECONDARY PAYER SAVINGS All States
CMS 1572AHHA SURVEY AND DEFICIENCIES REPORT All States
CMS 1666REGIONAL OFFICE REQUEST FOR ADDITIONAL INFORMATION All States
CMS 1696APPOINTMENT OF REPRESENTATIVE All States
CMS 1771ATTENDING PHYSICIANS STATEMENT AND DOCUMENTATION FOR MEDICARE EMERGENCY All States
CMS 179TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL All States
CMS 1856Request for Certification in the Medicare and/or Medicaid Program to Provide Outpatient Physical Therapy and/or Speech Pathology Ser... All States
CMS 1880REQUEST FOR CERTIFICATION AS SUPPLIER OF PORTABLE XRAY SERVICES All States
CMS 1882PORTABLE XRAY SURVEY REPORT All States
CMS 1893OUTPATIENT PHYSICAL THERAPY - SPEECH PATHOLOGY SURVEY REPORT All States
CMS 1965REQUEST FOR HEARING - PART B MEDICARE CLAIM All States
CMS 1980CARRIER OR INTERMEDIARY REQUEST FOR SSO ASSISTANCE All States
CMS 20007NOTICE OF EXCLUSIONS FROM MEDICARE BENEFITS (NEMB) All States
CMS 20014NOTICE OF EXCLUSIONS FROM MEDICARE BENEFITS - SKILLED NURSING FACILITY (NEMB-SNF) All States
CMS 20017ADVISORY PANEL ON AMBULATORY PAYMENT All States
CMS 20027MEDICARE REDETERMINATION REQUEST FORM All States
CMS 20031TRANSFER (ASSIGNMENT) OF APPEAL RIGHTS All States
CMS 20033MEDICARE RECONSIDERATION REQUEST FORM All States