Sunday, August 18, 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 416Early ad Periodic Screening Diagnostic and Treatment Participation Report All States
CMS 417HOSPICE REQUEST FOR CERTIFICATION IN MEDICARE All States
CMS 437AREHAB UNIT CRITERIA WORKSHEET All States
CMS 437BREHAB HOSPITAL CRITERIA WORKSHEET All States
CMS 437PSYCHIATRIC UNIT CRITERIA WORKSHEET All States
CMS 460MEDICARE PARTICIPATING PHYSICIAN OR SUPPLIER AGREEMENT All States
CMS 462ABCLIA ADVERSE ACTION EXTRACT All States
CMS 462LADVERSE ACTI0N EXTRACT FOR SNFs AND NFs All States
CMS 484CERTIFICATE OF MEDICAL NECESSITY - Oxygen DME 484.03 All States
CMS 5011A-BREQUEST FOR MEDICARE HEARING BY ADMINISTRATIVE LAW JUDGE All States
CMS 562Medicare/Medicaid/CLIA Complaint Form All States
CMS 576AHealth Insurance Benefits Agreement with Organ Procurement Organization All States
CMS 576Organ Procurement Request for Designation as an OPO All States
CMS 588Electronic Funds Transfer (EFT) Authorization Agreement All States
CMS 632FOIFREEDOM OF INFORMATION ACT REQUEST All States
CMS 633Invoice of Fees for FOIA Services All States
CMS 636TRANSMITTAL NOTICE HEARING CASE All States
CMS 643 (28 KB)Hospice Survey AND Deficiencies Report All States
CMS 668BPost Lab Survey - CLIA All States
CMS 671LTC Facility Application for Medicare/Medicaid All States
CMS 672Resident Census and Conditions of Residents All States
CMS 673Extended/Partial Extended Survey Worksheet All States
CMS 677Medication Pass Worksheet All States
CMS 700Plan of Treatment for Outpatient Rehab All States
CMS 701Updated Plan of Progress for Outpatient Rehab All States
CMS 724Medicare/Medicaid Psychiatric Hospital Survey Data All States
CMS 725Surveyor Worksheet for Psychiatric Hospital Review:Two Special Conditions All States
CMS 726CMS Death Record Review Data Sheet All States
CMS 727CMS Nursing Complement Data All States
CMS 728CMS Staff Data All States
CMS 729Data Collection Medical Staff Coverage All States
CMS 801Offsite Survey Prep Worksheet All States
CMS 802PRoster/Sample Matrix Provider Instructions All States
CMS 802Roster/Sample Matrix All States
CMS 802SRoster/Sample Matrix Instruction for Surveyors All States
CMS 803General Observations of Facility All States
CMS 804Kitchen/Food Service Observation All States
CMS 805Resident Review Worksheet All States
CMS 806AQuality of Life Assessment--Resident All States
CMS 806BQuality of Life Assessment--Group All States
CMS 806CQuality of Life Assessment--Family All States
CMS 807Surveyor Notes Worksheet All States
CMS 820IN-CENTER HEMODIALYSIS (HD) CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2005 All States
CMS 821PERITONEAL DIALYSIS CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2005 All States
CMS 838Medicare Credit Balance Reporting Requirements All States
CMS 846Certificate of Medical Necessity - Pneumatic Compression Devices DME 04.04B All States
CMS 847Certificate of Medical Necessity - Osteogenesis Stimulators - DME 04.04C All States
CMS 848Certificate of Medical Necessity - Transcutaneous Electrical Nerve Stimulator (TENS) - DME 06.03B All States
CMS 849Certificate of Medical Necessity - Seat Lift Mechanisms - DME 07.03A All States
CMS 854Certificate of Medical Necessity - DME 11.02 All States