Wednesday, August 21, 2019

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 20034A/BREQUEST FOR MEDICARE HEARING BY AN ADMINISTRATIVE LAW JUDGE All States
CMS 20040Regional Office Meeting/Speaker Request Form All States
CMS 20041Speech Invitation Request Background Information All States
CMS 20042Section 1011 Dispute Resolution Request All States
CMS 2007PROVIDER TIE IN NOTICE All States
CMS 209LABORATORY PERSONNEL REPORT (CLIA) All States
CMS 216ORGAN PROCUREMENT ORGANIZATION-HISTO-COMPATIBILITY LAB STATEMENT OF REIMBURSABLE COSTS All States
CMS 2501RECONSIDERATION DETERMINATION All States
CMS 2567BPOST-CERTIFICATION REVISIT REPORT All States
CMS 2567STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION All States
CMS 2628 (35 KB)Foreign HI Claim or Emergency Services Accessibility Documentation and Determination All States
CMS 2728ESRD MEDICAL EVIDENCE REPORT MEDICARE ENTITLEMENT AND/OR PATIENT REGISTRATION All States
CMS 2744AESRD FACILITY SURVEY (DIALYSIS UNIT ONLY) All States
CMS 2744BEND STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM ESRD FACILITY SURVEY (TRANSPLANT CENTERS ONLY) All States
CMS 2746ESRD DEATH NOTIFICATION All States
CMS 2786MFIRE SAFETY SURVEY - RATING RESIDENTS - 2000 CODE All States
CMS 2786RFIRE SAFETY SURVEY REPORT 2000 CODE - HEALTH CARE - MEDICARE - MEDICAID All States
CMS 2786SFIRE SAFETY SURVEY REPORT SHORT FORM - MEDICARE - MEDICAID All States
CMS 2786TFIRE/SMOKE ZONE EVALUATION WORKSHEET FOR HEALTH CARE FACILITIES - 2000 CODE All States
CMS 2786UFIRE SAFETY SURVEY REPORT - AMBULATORY SURGICAL CENTERS - MEDICARE - 2000 CODE All States
CMS 2786VFIRE SAFETY SURVEY REPORT ICF/MR - SMALL FACILITIES - 2000 CODE All States
CMS 2786WFIRE SAFETY SURVEY REPORT - ICF/MR - LARGE FACILITIES - 2000 CODE All States
CMS 2786XREPORT - ICF/MR APARTMENT HOUSE - 2000 CODE All States
CMS 2786YFIRE SAFETY SURVEY REPORT ICF/MR - SMALL FSES - 2000 CODE All States
CMS 2802BREQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR HOSPICE All States
CMS 2802CREQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR HOME HEALTH AGENCY All States
CMS 2802DREQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR AMBULATORY SURGICAL CENTER All States
CMS 2802EREQUEST FOR VALIDATION OF ACCREDITATION FOR CRITICAL ACCESS HOSPITAL SURVEY All States
CMS 2802REQUEST FOR VALIDATION OF ACCREDITATION All States
CMS 2878ACCREDITED HOSPITAL ALLEGATIONS REPORT All States
CMS 29REQUEST TO ESTABLISH ELIGIBILITY TO PARTICIPATE IN HI FOR AGED/DISABLED TO PROVIDE RURAL HEALTH CLINIC SERVICES All States
CMS 3070GICF/MR SURVEY REPORT All States
CMS 3070HICF/MR DEFICIENCIES REPORT All States
CMS 3070IINDIVIDUAL OBSERVATION WORKSHEET All States
CMS 339PROVIDER COST REPORT REIMBURSEMENT QUESTIONNAIRE All States
CMS 3509ALJ MEDICARE CASE FOLDER (CMS) All States
CMS 352PART A RECONSIDERATION INPUT RECORD All States
CMS 353PART A PREHEARING INPUT RECORD All States
CMS 359CORF REPORT FOR CERTIFICATION TO PARTICIPATE IN MEDICARE All States
CMS 360CORF SURVEY REPORT All States
CMS 36CONSENT FOR HOME VISIT (English/Spanish) All States
CMS 36PCONSENT FOR HOME VISIT FOR PACE SERVICES EVALUATION All States
CMS 370HEALTH INSURANCE BENEFITS AGREEMENT-AMBULATORY SURGICAL CENTER All States
CMS 377AMBULATORY SURGICAL CENTER REQUEST FOR CERTIFICATION IN MEDICARE All States
CMS 378AMBULATORY SURGICAL CENTER SURVEY REPORT All States
CMS 379FINANCIAL STATEMENT OF DEBTOR All States
CMS 381MODEL LETTER REQUESTING IDENTIFICATION OF EXTENSION LOCATIONS All States
CMS 383HEALTH INSURANCE CASE SUMMARY All States
CMS 384QIO CASE SUMMARY All States
CMS 4040REQUEST FOR ENROLLMENT IN SUPPLEMENTARY MEDICAL INSURANCE (English / Spanish) All States