U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services Forms

This form is used for certifying the medical necessity of oxygen equipment.

This is a legal document which must be completed to prove the group health plan coverage based on your or your spouse's current employment.

This document is used for submitting an application for Civil Money Penalty (CMP) reinvestment related to Coronavirus Disease 2019 (COVID-19) communicative technology requests.

This report provides monthly data on applications, eligibility determinations, and enrollment for the Medicaid and Children's Health Insurance Program (CHIP) in March 2015. It helps analyze the usage and effectiveness of these healthcare programs in the United States.

This document provides projections for national health expenditure in the United States from 2012 to 2022. It shows predicted trends and estimates for healthcare spending over the next decade.

This document provides projections of national health expenditure for the years 2019 to 2028. It predicts how much money is expected to be spent on healthcare in the United States during this time period.

This Form is used for applying for Civil Money Penalty Reinvestment for projects related to Covid-19 and communicative technology.

This document is a template for applying for civil money penalty reinvestment, specifically related to the Coronavirus Disease 2019 (Covid-19) in-person visitation AIDS request.

This form is used for Comprehensive Outpatient Rehabilitation Facilities (CORFs) to report their certification to participate in the Medicare Program.

This document lists the different groups of people who may be eligible for Medicaid coverage in the United States.

This document is a form used to apply for the use of civil money penalty funds.

This document explains the coverage that Medicare provides for healthcare services received outside of the United States. It includes information on the limitations and requirements for receiving medical care abroad under Medicare.

This document is for understanding Medicare coverage outside of the United States. It provides information on what medical services are covered and the limitations of coverage when traveling or living abroad.

This Form is used for reporting the death of a patient with End Stage Renal Disease (ESRD) to the Medical Information System.

This application is supposed to be used by individuals when they want to apply for enrollment in Medicare Part B, insurance which provides outpatient medical coverage.

This Form is used for requesting payment for medical expenses by the patient.

This form is used to report the findings of a comprehensive survey of outpatient rehabilitation facilities.

This form is used for conducting site investigations at independent diagnostic testing facilities. It helps gather information about the facility's location, equipment, and personnel to ensure compliance with CMS regulations.

This Form is used for reporting credit balances to Medicare, which refers to overpayments that need to be refunded. It helps healthcare providers accurately calculate and reconcile outstanding credit balances.

This form is used for entering into a data use agreement for limited data sets under CMS-R-0235L.

This form is used for agreeing to use Centers for Medicare and Medicaid Services (CMS) data containing individual identifiers.

This form is used for conducting surveys on End Stage Renal Disease (ESRD) facilities that provide dialysis treatment. It helps gather medical information about these facilities.

This Form is used for submitting a Medicare Reconsideration Request at the 2nd Level of Appeal. It allows individuals to request a review of a previous Medicare determination made by Medicare Administrative Contractors (MACs) or other entities.

This form is used for healthcare providers to apply for enrollment in the Medicare program.

This form is used to collect medical information about end stage renal disease (ESRD) facilities that also serve as transplant centers.