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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.
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Form # Form Title Revision Date
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
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 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 2015-03-01
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) 2011-09-01
CMS 339 PROVIDER COST REPORT REIMBURSEMENT QUESTIONNAIRE 2006-04-30
CMS 416 Early ad Periodic Screening Diagnostic and Treatment Participation Report 1999-06-01
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 2004-05-01
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 484 CERTIFICATE OF MEDICAL NECESSITY - Oxygen DME 484.03 2011-11-01
CMS 576 Organ Procurement Request for Designation as an OPO 1993-01-01
CMS 576A Health Insurance Benefits Agreement with Organ Procurement Organization 2006-06-30
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 2008-12-01
CMS 359 CORF REPORT FOR CERTIFICATION TO PARTICIPATE IN MEDICARE 2003-07-01
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 1980-10-01
CMS 1557 SURVEY REPORT FORM - CLIA 1992-09-01
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 2003-10-01
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 2015-07-01
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 2014-09-01
CMS 802S Roster/Sample Matrix Instruction for Surveyors 2012-04-01
CMS 802P Roster/Sample Matrix Provider Instructions 2012-04-01
CMS 802 Roster/Sample Matrix 2012-04-01
CMS 805 Resident Review Worksheet 10/01/2010
CMS 672 Resident Census and Conditions of Residents 2012-05-01
CMS 40B Application for Enrollment in Medicare - Part B (Medical Insurance) 2014-04-21
CMS R-193 IMPORTANT MESSAGE FROM MEDICARE (IM) 2010-07-01
CMS 1728 HOME HEALTH AGENCY COST REPORT 2001-06-01
CMS 179 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL 1992-07-01
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 2016-10-01
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 2015-05-01
CMS 18F APPLICATION FOR HOSPITAL INSURANCE (English / Spanish) 02/01/1991
CMS R-131 ADVANCE BENEFICIARY NOTICE (ABN) 2011-03-01
CMS 265 INDEPENDENT RENAL DIALYSIS FACILITY COST REPORT 2005-03-01
CMS 417 HOSPICE REQUEST FOR CERTIFICATION IN MEDICARE 2010-08-01
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 2015-11-01
CMS 643 (28 KB) Hospice Survey AND Deficiencies Report 2008-06-01
CMS R-285 Request for Retirement Benefit Information 03/01/2006
CMS 1882 PORTABLE XRAY SURVEY REPORT 2009-02-01
CMS 588 Electronic Funds Transfer (EFT) Authorization Agreement 2013-09-01
CMS 10221 Independent Diagnostic Testing Facilities-Site Investigation 2012-08-01
CMS 460 MEDICARE PARTICIPATING PHYSICIAN OR SUPPLIER AGREEMENT 2010-04-01
CMS 1500 Health Insurance Claim Form 2012-02-01
CMS 379 FINANCIAL STATEMENT OF DEBTOR 07/01/2007
CMS 29 VERIFICATION OF CLINIC DATA – RURAL HEALTH CLINIC PROGRAM 2011-11-01
CMS 2786X Fire Safety Survey Report - ICF-IID (Apartment House) 2012 Life Safety Code 2016-10-01
CMS 2786Y Fire Safety Evaluation System - ICF-IID (Small Facilities) 2012 Life Safety Code 2016-10-01
CMS 2786U Fire Safety Survey Report - ASC & ESRD 2012 Life Safety Code 2016-10-01
CMS 2786T Fire Safety Evaluation System - Health Care 2012 Life Safety Code 2016-10-01
CMS 2786R Fire Safety Survey Report - Health Care 2012 Life Safety Code 2016-10-01
CMS 2786W Fire Safety Survey Report - ICF-IID (Large Facilities) 2012 Life Safety Code 2016-10-01
CMS 2786V Fire Safety Survey Report - ICF-IID (Small Facilities) 2012 Life Safety Code 2016-10-01
CMS 2786M Worksheet for Determining Evacuation Capability - ICF-IID (Existing Facilities Only) 2012 Life Safety Code 2016-10-01
CMS 3070I INDIVIDUAL OBSERVATION WORKSHEET 1995-10-01
CMS 3070H ICF/IID Deficiencies Report 2013-03-01
CMS 3070G ICF/IID Survey Report 2013-03-01
CMS L564 REQUEST FOR EMPLOYMENT INFORMATION 2014-02-12
CMS 10269 CMN Positive Airway Pressure (PAP)Devices for Obstructive Sleep Apnea 12/01/2009
CMS 2567 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION 1999-02-01
CMS 20017 ADVISORY PANEL ON HOSPITAL OUTPATIENT PAYMENT 2011-05-01
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 2006-01-01
CMS 10125 DME Information Form - External Infusion Pumps DME 09.03 2005-09-30
CMS 10126 DME Information Form - Enteral and Parenteral Nutrition DME 10.03 2005-09-30
CMS 847 Certificate of Medical Necessity - Osteogenesis Stimulators - DME 04.04C 2005-09-30
CMS 849 Certificate of Medical Necessity - Seat Lift Mechanisms - DME 07.03A 2005-09-30
CMS 854 Certificate of Medical Necessity - DME 11.02 2005-09-30
CMS 848 Certificate of Medical Necessity - Transcutaneous Electrical Nerve Stimulator (TENS) - DME 06.03B 2005-09-30
CMS 846 Certificate of Medical Necessity - Pneumatic Compression Devices DME 04.04B 2005-09-30
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 2006-08-01
CMS 1957 SSO REPORT OF STATE BUY IN PROBLEM 1994-03-01
CMS 2540-96 SNF AND SNF HEALTH CARE COMPLEX COST REPORT 2006-05-01
CMS 1490S PATIENT'S REQUEST FOR MEDICAL PAYMENT (English/Spanish) 2005-01-01
CMS 10003-NDMCP NOTICE OF DENIAL OF MEDICAL COVERAGE/PAYMENT ("INTEGRATED DENIAL NOTICE") 2013-06-01
CMS 632FOI FREEDOM OF INFORMATION ACT REQUEST 2013-03-01
CMS 633 Invoice of Fees for FOIA Services 01/01/2008
CMS 1450 UB-04 Uniform Bill 2007-03-01
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 2011-07-01
CMS 855B Medicare Enrollment Application - Clinics/Group Practices and Certain Other Suppliers 2011-07-01
CMS 855I Medicare Enrollment Application - Physicians and Non-Physician Practitioners 2011-07-01
CMS 855O Medicare Enrollment Application - Registration For Eligible Ordering and Referring Physicians and Non-Physician Practitioners 2013-01-01
CMS 10069 Medicare Waiver Demonstration Application 12/01/2010
CMS 855R Medicare Enrollment Application - Reassignment of Medicare Benefits 2016-04-01
CMS 855S Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers 2016-05-01
CMS 10287 Medicare Quality of Care Complaint Form 2015-11-01
CMS 668B Post Lab Survey - CLIA 2012-01-01
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 2006-08-01
CMS 10164 Centers for Medicare and Medicaid Services EDI Registration Form; and EDI Enrollment Form 2006-03-01
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) 2004-02-01
CMS 2744A ESRD FACILITY SURVEY (DIALYSIS UNIT ONLY) 2004-02-01
CMS 1515A-OBSOLETE HHA Functional Assessment Instrumental 2013-05-01
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) 2012-06-01
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 2013-01-01
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
CMS 20037 APPLICATION FOR ACCESS TO CMS COMPUTER SYSTEMS 2010-06-01
CMS-10455 Report of a Hospital Death Associated with Restraint or Seclusion 2013-11-01
CMS 20056 Medicare Adminstration Observation 2013-02-01
CMS 855C Medicare Enrollment Application 2014-04-01
CMS 855POH Annual Report of Physician-Owned Hospital Ownership and/or Investment Interest 2014-05-01