Forms

• Data Use Agreement (DUA)- Update to Existing DUA

  

• Data Use Agreement (DUA)- Limited Data Sets

  

• Data Use Agreement (DUA) (Agreement for use of Centers for Medicare and Medicaid Services (CMS) data containing individual-specific information

  

• CONSENT FOR HOME VISIT (English/Spanish)

  

• Centers for Medicare and Medicaid Services EDI Registration Form; and EDI Enrollment Form

  

• Annual Report of Physician-Owned Hospital Ownership and/or Investment Interest

  

• ADVISORY PANEL ON HOSPITAL OUTPATIENT PAYMENT

  

• ADVANCE BENEFICIARY NOTICE (ABN)

  

• Addendum to the Medicaid State Agency Data Use Agreement

  

• Section 1011 Provider Enrollment Application

  

• DME Information Form - External Infusion Pumps DME 09.03

  

• DME Information Form - Enteral and Parenteral Nutrition DME 10.03

  

• Section 1011 Provider Payment Determination

  

• Request for Section 1011 Hospital On-Call Payments to Physicians

  

• Notice of Denial of Medicare Prescription Drug Coverage

  

• Independent Diagnostic Testing Facilities-Site Investigation

  

• Data Use Agreement (DUA) Certficate Of Disposition (COD) For Data Acquired From The Centers For Medicare & Medicaid Services (CMS)

  

• Medicare Quality of Care Complaint Form

  

• Clinical Laboratory Improvement Amendments Of 1988 (ClIA) Application For Certification

  

• Health Insurance Claim Form