Centers for Medicare and Medicaid Form CMS & HFCA Forms in Microsoft Word page 1

Centers for Medicare & Medicaid Services (CMS) and Health Care Financing Administration (HCFA) Forms in Microsoft Word - page 1 of 3

All forms are Microsoft Word documents that are completely fillable and easy to use, save, and copy. Our MS Office-certified designers make current, correct, and easy government forms in Word with automatic form fill features. We always do a careful proof of each form to be sure it looks just like the federal form. We are happy to answer questions that you have, and we usually e-mail your document to you right away! The only information we receive from PayPal to contact you is your email address, so if you prefer that we send your form to another e-mail or if you typed it in wrong, e-mail us (forms@formsinword.com) about where to send your form (include your phone number). Thank you for using Forms in Word! Questions? E-mail (fastest service!) or call 907-745-5674 for personalized service!

Note: There are so many CMS forms that we have put them on 3 pages; here is your guide for locating the correct form
1. CMS Page 1 (10003 - 2567) - 2. CMS Page 2 (2567B - 726) - 3. CMS Page 3 (727 - R296 + HFCA forms).

Form No.	Title	Price in Word	Buy Now in Word
UB 04 Form	Update of CMS 1450 required beginning March 2007.	$14.50
CMS 10003NDMC	NOTICE OF DENIAL OF MEDICAL COVERAGE	$14.50
CMS 10003-NDP	NOTICE OF DENIAL OF PAYMENT	$14.50
CMS 10036	Inpatient Rehabilitation Facility-Patient Assessment Instrument	$14.50
CMS 10055	SKILLED NURSING FACILITY ADVANCED BENEFICIARY NOTICE	$14.50
CMS 10095 A-B	NOTICE & EXPLANATION OF MEDICARE NON-COVERAGE	$14.50
CMS 10111	NOTICE OF EXCLUSIONS FROM MEDICARE BENEFITS - HOME HEALTH AGENCY (NEMB-HHA)	$14.50
CMS 10113	MEDICARE REPLACEMENT DRUG DEMONSTRATION INSTRUCTIONS & FORMS	$14.50
CMS 10114	National Provider Identifier (NPI) Application/Update Form	$14.50
CMS 10115	Section 1011 Provider Enrollment Application	$14.50
CMS 10123	Expedited Review Notice - Notice of Medicare Provider Non-Coverage	$14.50
CMS 10124	Expedited Review Notice - Detailed Explanation of...Non-Coverage	$14.50
CMS 10125	DME Information Form - External Infusion Pumps DME 09.03	$14.50
CMS 10126	DME Information Form - Enteral and Parenteral Nutrition DME 10.03	$14.50
CMS 10130A	Section 1011 Provider Payment Determination	$14.50
CMS 10130B	Request for Section 1011 Hospital On-Call Payments to Physicians	$14.50
CMS 10146	Notice of Denial of Medicare Prescription Drug Coverage English/Spanish	$14.50
CMS 10156	Retiree Drug Subsidy	$14.50
CMS 10167	Competitive Acquisition Program (CAP) for Medicare Part B Drugs - CAP Physician Election Agreement	$14.50
CMS 10175	Electronic File Interchange Organization (EFIO) Certification Statement	$14.50
CMS 116	CLINICAL LAB IMPROVEMENT AMENDMENTS (CLIA) APPLICATION FOR CERTIFICATION	$14.50
CMS 1450 (or HCFA 1450)	UB-92 MEDICARE UNIFORM INSTITUTIONAL PROVIDER BILL	$24.99
CMS 1490S	PATIENT'S REQUEST FOR MEDICAL PAYMENT	$14.50
CMS 1490U	REQUEST FOR MEDICARE PAYMENT BY ORGANIZATIONS	$14.50
CMS 1491	REQUEST FOR MEDICARE PAYMENT, AMBULANCE	Cancelled by CMS	Form cancelled by CMS
CMS 1500	HEALTH INSURANCE CLAIM FORM - One of our most popular forms! Recently updated!.	$24.99
CMS 1513	DISCLOSURE OF OWNERSHIP & CONTROL INTEREST STATEMENT	$14.50
CMS 1515A	HOME HEALTH FUNCTIONAL ASSESSMENT INSTRUMENT: MODULE A	$14.50
CMS 1515B	HOME HEALTH FUNCTIONAL ASSESSMENT INSTRUMENT: MODULE B	$14.50
CMS 1515C	HOME HEALTH FUNCTIONAL ASSESSMENT MODULE C: HOME VISIT	$14.50
CMS 1515D	HOME HEALTH FUNCTIONAL ASSESSMENT PATIENT CARE: MODULE D	$14.50
CMS 1515E	HOME HEALTH FUNCTION & CARE SUMMARY: MODULE E	$14.50
CMS 1515F	CALENDAR WORKSHEET - PRESCRIBED VISITS	$14.50
CMS 1537C	MEDICARE/MEDICAID HOSPITAL SWING-BED SURVEY REPORT	$14.50
CMS 1537E	HOSPITAL SURVEY REPORT CRUCIAL DATA EXTRACT	$14.50
CMS 1539	MEDICARE/MEDICAID CERTIFICATION & TRANSMITTAL	$14.50
CMS 1541A	RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN EMERGENCY CASES	$14.50
CMS 1541B	RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN EMERGENCY CASES INVESTIGATION REPORT	$14.50
CMS 1557	SURVEY REPORT FORM - CLIA	$14.50
CMS 1561	HEALTH INSURANCE BENEFIT AGREEMENT	$14.50
CMS 1561A	HEALTH INSURANCE BENEFIT AGREEMENT - RURAL HEALTH CLINIC	$14.50
CMS 1563	MONTHLY INTERMEDIARY REPORT ON MEDICARE SECONDARY PAYER SAVINGS	$14.50
CMS 1564	MONTHLY CARRIER REPORT ON MEDICARE SECONDARY PAYER SAVINGS	$14.50
CMS 1572A	HHA SURVEY & DEFICIENCIES REPORT	$14.50
CMS 1592	SMI PREMIUM ACCOUNTING FORM	$14.50
CMS 1666	REGIONAL OFFICE REQUEST FOR ADDITIONAL INFORMATION	$14.50
CMS 1696	APPOINTMENT OF REPRESENTATIVE	$14.50
CMS 1728	HOME HEALTH AGENCY COST REPORT	Please email us	Please email us the report for an estimate
CMS 1763	REQ FOR TERMINATION OF PREMIUM HI/SMI	Not in Word	Not in Word
CMS 1771	ATTENDING PHYSICIANS STATEMENT AND DOCUMENTATION FOR MEDICARE EMERGENCY	$14.50
CMS 179	TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL	$14.50
CMS 1856	REQUEST TO ESTABLISH ELIGIBILITY IN MEDICARE AND/OR MEDICAID PROGRAM	$14.50
CMS 1880	REQUEST FOR CERTIFICATION AS SUPPLIER OF PORTABLE XRAY SERVICES	$14.50
CMS 1882	PORTABLE XRAY SURVEY REPORT	$14.50
CMS 1893	OUTPATIENT PHYSICAL THERAPY - SPEECH PATHOLOGY SURVEY REPORT	$14.50
CMS 18F	APPLICATION FOR HOSPITAL INSURANCE :	$14.50
CMS 1938	SSO REQUEST FOR CARRIER/INTERMEDIARY ASSISTANCE	$14.50
CMS 1957	SSO REPORT OF STATE BUY IN PROBLEM	$14.50
CMS 1960	REQUEST FOR EVIDENCE OF MEDICAL NECESSITY	$14.50
CMS 1964	REQUEST FOR REVIEW OF PART B MEDICARE CLAIM	$14.50
CMS 1965	REQUEST FOR HEARING - PART B MEDICARE CLAIM	$14.50
CMS 1980	CARRIER OR INTERMEDIARY REQUEST FOR SSO ASSISTANCE	$14.50
CMS 1984	HOSPICE COST REPORT