Forms

Medicare Enrollment Application for Eligible Ordering and Referring Physicians and Non-physician Practitioners

Medicare Enrollment Application for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers

Advance Beneficiary Notice
(Advance Beneficiary Notice of Non-coverage) The ABN is a notice given to beneficiaries of Original Medicare to convey that Medicare is not likely to provide coverage in a specific case. “Notifiers” include physicians, providers (including institutional providers like outpatient hospitals), practitioners, and suppliers paid under Part B (including independent laboratories), as well as hospice providers and religious non-medical health care institutions (RNHCIs) paid exclusively under Part A.

New UB-04 Form

The Office of Management and Budget (OMB) and the National Uniform Billing Committee (NUBC) have approved the UB-04 claim form, also known as the CMS-1450 form. The UB-04 claim form will accommodate the National Provider Identifier (NPI) and has incorporated other important changes.

Medicare Enrollment Application - Physicians and Non-Physician Practitioners
A Physician or Non-Physician Practitioner must complete The CMS-855I form if they render medical services to Medicare beneficiaries. This form is processed through the Medicare carrier.

Medicare Enrollment Application for Reassignment of Medicare Benefits
An individual who renders services and seeks to reassign his/her benefits to an eligible entity must complete the CMS-855R form for each entity eligible to receive reassigned benefits. The person must be enrolled in the Medicare program as an individual before reassigning his/her benefits. The CMS-855R form may be submitted concurrently with the CMS-855 form.

Electronic Funds Transfer (EFT) Authorization Agreement
New enrollees are required to complete the most current Electronic Funds Transfer (EFT) authorization agreement (CMS-588). The account must exclusively bear the name of the physician or individual practitioner, or the legal business name of the person or entity enrolled with Medicare. It cannot be a personal account shared with a significant other or any other party.

Financial Statement of Debtor
Sole proprietors must use the CMS Financial Statement of Debtor form (CMS-379) to request an extended repayment plan (ERP) for an overpayment debt.

1500 - Health Insurance Claim Form
The CMS-1500 form (Health Insurance Claim Form) is sometimes referred to as the AMA (American Medical Association) form. CMS-1500 is the prescribed form for claims prepared and submitted by physicians or suppliers (except for ambulance suppliers), whether or not the claims are assigned.

Medicare Participating Physician or Supplier Agreement
The CMS-460 form is a formal recognition that you will accept assignment of benefits for all Medicare beneficiaries (patients). It must be submitted either within 90 days of initial enrollment with Medicare OR during the annual Open Enrollment period (typically mid-November through December 31st). Accepting an assignment means you agree to be paid the Medicare allowed amount for services provided to such beneficiaries.

Patient's Request for Medical Payment
The Patient's Request for Medical Payment form (CMS-1490S) is the primary claim form that is filed on the beneficiaries’ behalf (replaces HCFA-1490). This form is used by the beneficiary in order to file a claim with Medicare for services and/or supplies received.

Medicare Enrollment Application - Clinics/Group Practices and Certain Other Suppliers
This application (CMS-855B) is to be completed by a supplier (e.g. ambulance company, physician group, Part B drug vendor) that will bill Medicare carriers for medical services furnished to Medicare beneficiaries. It is not to be used to enroll individuals.

Forms