http://www.cms.hhs.gov/CMSForms/CMSForms/List.aspThe 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.Fri, 03 Mar 2006 10:06:00 EST ESThttp://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS017339http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS017339Tue, 23 Aug 2005 10:16:00 EST<b>Form #:</b> CMS 40B<br /><b>Form Title:</b> APPLICATION FOR ENROLLMENT IN MEDICARE<br /><b>Revision Date:</b> 01/01/1990<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS017341http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS017341Tue, 23 Aug 2005 10:17:00 EST<b>Form #:</b> CMS 40F<br /><b>Form Title:</b> APPLICATION FOR ENROLLMENT IN MEDICAL INS UNDER MEDICARE<br /><b>Revision Date:</b> 11/01/1981<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS017344http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS017344Tue, 23 Aug 2005 10:21:00 EST<b>Form #:</b> CMS L457<br /><b>Form Title:</b> ACKNOWLEDGMENT OF REQUEST FOR MEDICARE MEDICAL INSURANCE TERMINATION<br /><b>Revision Date:</b> 02/01/2003<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS017345http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS017345Tue, 23 Aug 2005 10:23:00 EST<b>Form #:</b> CMS L458<br /><b>Form Title:</b> ACKNOWLEDGMENT OF REQUEST FOR PREMIUM HOSPITAL INSURANCE TERMINATION<br /><b>Revision Date:</b> 02/01/2003<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS017352http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS017352Tue, 23 Aug 2005 10:31:00 EST<b>Form #:</b> CMS 1592<br /><b>Form Title:</b> SMI PREMIUM ACCTG FORM<br /><b>Revision Date:</b> 07/01/1986<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS017355http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS017355Tue, 23 Aug 2005 10:37:00 EST<b>Form #:</b> CMS 1960<br /><b>Form Title:</b> REQUEST FOR EVIDENCE OF MEDICAL NECESSITY<br /><b>Revision Date:</b> 05/01/1969<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS017357http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS017357Tue, 23 Aug 2005 10:39:00 EST<b>Form #:</b> CMS 2384<br /><b>Form Title:</b> THIRD PARTY PREMIUM BILLING REQUEST, MEDICARE<br /><b>Revision Date:</b> 11/01/2003<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS017358http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS017358Tue, 23 Aug 2005 10:41:00 EST<b>Form #:</b> CMS 2690<br /><b>Form Title:</b> REQ FOR CANCELLATION OF SMI<br /><b>Revision Date:</b> 03/01/1978<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019166http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019166Tue, 30 Aug 2005 08:40:00 EST<b>Form #:</b> CMS 265<br /><b>Form Title:</b> INDEPENDENT RENAL DIALYSIS FACILITY COST REPORT<br /><b>Revision Date:</b> 03/01/2005<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019465http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019465Tue, 30 Aug 2005 14:29:00 EST<b>Form #:</b> HCFA 378E<br /><b>Form Title:</b> AMBULATORY SURGICAL CTR REPORT--CRUCIAL DATA EXTRACT<br /><b>Revision Date:</b> N/A<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019468http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019468Tue, 30 Aug 2005 14:32:00 EST<b>Form #:</b> CMS 820<br /><b>Form Title:</b> IN-CENTER HEMODIALYSIS (HD) CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2005<br /><b>Revision Date:</b> 01/01/2005<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019471http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019471Tue, 30 Aug 2005 14:34:00 EST<b>Form #:</b> CMS 821<br /><b>Form Title:</b> PERITONEAL DIALYSIS CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2005<br /><b>Revision Date:</b> 01/01/2005<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019497http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019497Tue, 30 Aug 2005 14:51:00 EST<b>Form #:</b> CMS 2088-92<br /><b>Form Title:</b> OUTPATIENT REHAB PROVIDER COST REPORT<br /><b>Revision Date:</b> 12/01/2004<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019503http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019503Tue, 30 Aug 2005 14:53:00 EST<b>Form #:</b> CMS 2540S-97<br /><b>Form Title:</b> SNF AND SNF HEALTH CARE COMPLEX COST REPORT<br /><b>Revision Date:</b> 10/01/1999<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019508http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019508Tue, 30 Aug 2005 14:57:00 EST<b>Form #:</b> CMS 10055<br /><b>Form Title:</b> SKILLED NURSING FACILITY ADVANCED BENEFICIARY NOTICE<br /><b>Revision Date:</b> N/A<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019523http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019523Tue, 30 Aug 2005 15:03:00 EST<b>Form #:</b> CMS 20007<br /><b>Form Title:</b> NOTICE OF EXCLUSIONS FROM MEDICARE BENEFITS (NEMB)<br /><b>Revision Date:</b> 01/01/2003<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019526http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019526Tue, 30 Aug 2005 15:04:00 EST<b>Form #:</b> CMS 20014<br /><b>Form Title:</b> NOTICE OF EXCLUSIONS FROM MEDICARE BENEFITS - SKILLED NURSING FACILITY (NEMB-SNF)<br /><b>Revision Date:</b> N/A<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS020378http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS020378Thu, 01 Sep 2005 13:45:00 EST<b>Form #:</b> CMS 5011A-B<br /><b>Form Title:</b> REQUEST FOR MEDICARE HEARING BY ADMINISTRATIVE LAW JUDGE<br /><b>Revision Date:</b> 08/01/2005<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS020385http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS020385Thu, 01 Sep 2005 13:51:00 EST<b>Form #:</b> CMS 20027<br /><b>Form Title:</b> MEDICARE REDETERMINATION REQUEST FORM<br /><b>Revision Date:</b> 05/01/2005<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS020388http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS020388Thu, 01 Sep 2005 13:53:00 EST<b>Form #:</b> CMS 20031<br /><b>Form Title:</b> TRANSFER (ASSIGNMENT) OF APPEAL RIGHTS<br /><b>Revision Date:</b> 05/01/2005<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS020393http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS020393Thu, 01 Sep 2005 13:56:00 EST<b>Form #:</b> CMS 20033<br /><b>Form Title:</b> MEDICARE RECONSIDERATION REQUEST FORM<br /><b>Revision Date:</b> 05/01/2005<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS020396http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS020396Thu, 01 Sep 2005 13:58:00 EST<b>Form #:</b> CMS 20034A/B<br /><b>Form Title:</b> REQUEST FOR MEDICARE HEARING BY AN ADMINISTRATIVE LAW JUDGE<br /><b>Revision Date:</b> 08/01/2005<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS045083http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS045083Wed, 16 Nov 2005 13:31:00 EST<b>Form #:</b> CMS 2628 (35 KB)<br /><b>Form Title:</b> Foreign HI Claim or Emergency Services Accessibility Documentation and Determination<br /><b>Revision Date:</b> 05/01/1986<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS048905http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS048905Wed, 30 Nov 2005 15:13:00 EST<b>Form #:</b> CMS 636<br /><b>Form Title:</b> TRANSMITTAL NOTICE HEARING CASE<br /><b>Revision Date:</b> 06/01/1988<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS056040http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS056040Fri, 13 Jan 2006 08:57:00 EST<b>Form #:</b> CMS 20040<br /><b>Form Title:</b> Regional Office Meeting/Speaker Request Form<br /><b>Revision Date:</b> 12/01/05<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS056041http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS056041Fri, 13 Jan 2006 08:59:00 EST<b>Form #:</b> CMS 20041<br /><b>Form Title:</b> Speech Invitation Request Background Information<br /><b>Revision Date:</b> 12/01/05<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS058773http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS058773Tue, 28 Feb 2006 16:17:00 EST<b>Form #:</b> CMS 10156<br /><b>Form Title:</b> Retiree Drug Subsidy<br /><b>Revision Date:</b> 08/01/2005<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS056137http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS056137Thu, 23 Mar 2006 10:06:00 EST<b>Form #:</b> CMS 10146<br /><b>Form Title:</b> Notice of Denial of Medicare Prescription Drug Coverage English/Spanish<br /><b>Revision Date:</b> 11/01/05<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS017348http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS017348Thu, 23 Mar 2006 10:29:00 EST<b>Form #:</b> CMS 500<br /><b>Form Title:</b> NOTICE OF MEDICARE PREMIUM PAYMENT DUE (English / Spanish)<br /><b>Revision Date:</b> 01/01/2003<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS056691http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS056691Mon, 10 Apr 2006 14:23:00 EST<b>Form #:</b> CMS 10036<br /><b>Form Title:</b> Inpatient Rehabilitation Facility-Patient Assessment Instrument<br /><b>Revision Date:</b> 01/01/06<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019462http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019462Wed, 17 May 2006 10:18:00 EST<b>Form #:</b> CMS 339<br /><b>Form Title:</b> PROVIDER COST REPORT REIMBURSEMENT QUESTIONNAIRE<br /><b>Revision Date:</b> 04//30/2006<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS1184275http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS1184275Fri, 07 Jul 2006 09:21:00 EST<b>Form #:</b> CMS 10167<br /><b>Form Title:</b> Competitive Acquisition Program (CAP) for Medicare Part B Drugs - CAP Physician Election Agreement <br /><b>Revision Date:</b> 05/01/2006<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS1184680http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS1184680Fri, 21 Jul 2006 06:58:00 EST<b>Form #:</b> CMS 416<br /><b>Form Title:</b> Early ad Periodic Screening Diagnostic and Treatment Participation Report<br /><b>Revision Date:</b> 06/1999<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS017354http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS017354Wed, 09 Aug 2006 10:35:00 EST<b>Form #:</b> CMS 1957<br /><b>Form Title:</b> SSO REPORT OF STATE BUY IN PROBLEM<br /><b>Revision Date:</b> 03/01/1994<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS059203http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS059203Thu, 14 Sep 2006 14:20:00 EST<b>Form #:</b> CMS 10175<br /><b>Form Title:</b> Electronic File Interchange Organization (EFIO) Certification Statement<br /><b>Revision Date:</b> 08/01/2006<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS017353http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS017353Fri, 15 Sep 2006 10:33:00 EST<b>Form #:</b> CMS 1763<br /><b>Form Title:</b> REQ FOR TERMINATION OF PREMIUM HI/SMI<br /><b>Revision Date:</b> 05/01/1997<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019499http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019499Thu, 21 Sep 2006 14:52:00 EST<b>Form #:</b> CMS 2540-96<br /><b>Form Title:</b> SNF AND SNF HEALTH CARE COMPLEX COST REPORT<br /><b>Revision Date:</b> 05/01/2006<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS1183809http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS1183809Thu, 28 Sep 2006 15:00:00 EST<b>Form #:</b> CMS 10165<br /><b>Form Title:</b> Medicare Care Management Performance Demonstration Application to Participate<br /><b>Revision Date:</b> 06/23/2006<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS017356http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS017356Thu, 19 Oct 2006 09:00:00 EST<b>Form #:</b> CMS 2178<br /><b>Form Title:</b> HI/SMI ENTITLEMENT PROBLEM REFERRAL<br /><b>Revision Date:</b> 09/01/2006<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS1189402http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS1189402Tue, 28 Nov 2006 12:55:00 EST<b>Form #:</b> CMS 20042<br /><b>Form Title:</b> Section 1011 Dispute Resolution Request<br /><b>Revision Date:</b> 11/01/2006<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS1184635http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS1184635Mon, 08 Jan 2007 13:30:00 EST<b>Form #:</b> CMS 10126<br /><b>Form Title:</b> DME Information Form - Enteral and Parenteral Nutrition DME 10.03<br /><b>Revision Date:</b> 09/30/2005<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS1184634http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS1184634Mon, 08 Jan 2007 13:30:00 EST<b>Form #:</b> CMS 10125<br /><b>Form Title:</b> DME Information Form - External Infusion Pumps DME 09.03<br /><b>Revision Date:</b> 09/30/2005<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS020383http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS020383Wed, 10 Jan 2007 13:48:00 EST<b>Form #:</b> CMS 20017<br /><b>Form Title:</b> ADVISORY PANEL ON AMBULATORY PAYMENT<br /><b>Revision Date:</b> 01/01/2007<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS020293http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS020293Fri, 12 Jan 2007 10:58:00 EST<b>Form #:</b> CMS 2744B<br /><b>Form Title:</b> END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM ESRD FACILITY SURVEY (TRANSPLANT CENTERS ONLY)<br /><b>Revision Date:</b> 02/01/2004<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS049121http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS049121Tue, 16 Jun 2009 08:28:00 EST<b>Form #:</b> CMS 1515A<br /><b>Form Title:</b> HHA Functional Assessment Instrumental: Module A<br /><b>Revision Date:</b> 12/01/2005<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS048764http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS048764Wed, 24 Jun 2009 09:33:00 EST<b>Form #:</b> CMS 2786X<br /><b>Form Title:</b> REPORT - ICF/MR APARTMENT HOUSE - 2000 CODE<br /><b>Revision Date:</b> 06/01/2007<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009403http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009403Wed, 24 Jun 2009 09:34:00 EST<b>Form #:</b> CMS 2786Y<br /><b>Form Title:</b> FIRE SAFETY SURVEY REPORT ICF/MR - SMALL FSES - 2000 CODE<br /><b>Revision Date:</b> 06/01/2007<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009393http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009393Wed, 24 Jun 2009 09:34:00 EST<b>Form #:</b> CMS 2786T<br /><b>Form Title:</b> FIRE/SMOKE ZONE EVALUATION WORKSHEET FOR HEALTH CARE FACILITIES - 2000 CODE<br /><b>Revision Date:</b> 06/01/2007<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009392http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009392Wed, 24 Jun 2009 09:34:00 EST<b>Form #:</b> CMS 2786S<br /><b>Form Title:</b> FIRE SAFETY SURVEY REPORT SHORT FORM - MEDICARE - MEDICAID<br /><b>Revision Date:</b> 06/01/2007<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008881http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008881Wed, 24 Jun 2009 09:35:00 EST<b>Form #:</b> CMS 2786W<br /><b>Form Title:</b> FIRE SAFETY SURVEY REPORT - ICF/MR - LARGE FACILITIES - 2000 CODE<br /><b>Revision Date:</b> 06/01/2007<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008873http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008873Wed, 24 Jun 2009 09:35:00 EST<b>Form #:</b> CMS 2786V<br /><b>Form Title:</b> FIRE SAFETY SURVEY REPORT ICF/MR - SMALL FACILITIES - 2000 CODE<br /><b>Revision Date:</b> 06/01/2007<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009335http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009335Wed, 24 Jun 2009 09:35:00 EST<b>Form #:</b> CMS 2786R<br /><b>Form Title:</b> FIRE SAFETY SURVEY REPORT 2000 CODE - HEALTH CARE - MEDICARE - MEDICAID<br /><b>Revision Date:</b> 06/01/2007<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008774http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008774Wed, 24 Jun 2009 09:35:00 EST<b>Form #:</b> CMS 379<br /><b>Form Title:</b> FINANCIAL STATEMENT OF DEBTOR<br /><b>Revision Date:</b> 07/01/2007<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008849http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008849Wed, 24 Jun 2009 09:36:00 EST<b>Form #:</b> CMS 29<br /><b>Form Title:</b> REQUEST TO ESTABLISH ELIGIBILITY TO PARTICIPATE IN HI FOR AGED/DISABLED TO PROVIDE RURAL HEALTH CLINIC SERVICES<br /><b>Revision Date:</b> 05/01/1978<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008267http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008267Wed, 24 Jun 2009 09:37:00 EST<b>Form #:</b> CMS 30<br /><b>Form Title:</b> RURAL HEALTH CLINIC SURVEY REPORT<br /><b>Revision Date:</b> 05/01/1978<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009395http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009395Thu, 16 Jul 2009 13:03:00 EST<b>Form #:</b> CMS 2786U<br /><b>Form Title:</b> FIRE SAFETY SURVEY REPORT - AMBULATORY SURGICAL CENTERS - MEDICARE - 2000 CODE<br /><b>Revision Date:</b> 10/01/2008<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS1196256http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS1196256Mon, 27 Jul 2009 08:36:00 EST<b>Form #:</b> CMS 1450<br /><b>Form Title:</b> UB-04 Uniform Bill<br /><b>Revision Date:</b> 03/01/2007<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS1214081http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS1214081Mon, 27 Jul 2009 08:37:00 EST<b>Form #:</b> CMS 10252<br /><b>Form Title:</b> Instructions for Completing the Certificate of Data Destruction for Data Acquired from the Centers for Medicare & Medicaid Services<br /><b>Revision Date:</b> 12/01/2007<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012244http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012244Mon, 03 Aug 2009 13:28:00 EST<b>Form #:</b> CMS 10003-NDP<br /><b>Form Title:</b> NOTICE OF DENIAL OF PAYMENT<br /><b>Revision Date:</b> 01/01/2007<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012237http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012237Mon, 03 Aug 2009 13:33:00 EST<b>Form #:</b> CMS 10003NDMC<br /><b>Form Title:</b> NOTICE OF DENIAL OF MEDICAL COVERAGE<br /><b>Revision Date:</b> 01/01/2007<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006388http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006388Tue, 04 Aug 2009 14:05:00 EST<b>Form #:</b> CMS 643 (28 KB)<br /><b>Form Title:</b> Hospice Survey AND Deficiencies Report<br /><b>Revision Date:</b> 11/01/1994<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006200http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006200Thu, 06 Aug 2009 07:41:00 EST<b>Form #:</b> CMS 633<br /><b>Form Title:</b> Invoice of Fees for FOIA Services<br /><b>Revision Date:</b> 01/01/2008<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS048895http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS048895Thu, 06 Aug 2009 07:41:00 EST<b>Form #:</b> CMS 632FOI<br /><b>Form Title:</b> FREEDOM OF INFORMATION ACT REQUEST<br /><b>Revision Date:</b> 01/01/2008<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006601http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006601Thu, 06 Aug 2009 07:42:00 EST<b>Form #:</b> CMS 724<br /><b>Form Title:</b> Medicare/Medicaid Psychiatric Hospital Survey Data<br /><b>Revision Date:</b> 09/01/1994<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS017337http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS017337Thu, 06 Aug 2009 07:42:00 EST<b>Form #:</b> CMS 18F<br /><b>Form Title:</b> APPLICATION FOR HOSPITAL INSURANCE (English / Spanish)<br /><b>Revision Date:</b> 02/01/1991<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006605http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006605Thu, 06 Aug 2009 07:42:00 EST<b>Form #:</b> CMS 725<br /><b>Form Title:</b> Surveyor Worksheet for Psychiatric Hospital Review:Two Special Conditions<br /><b>Revision Date:</b> 09/01/1994<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006613http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006613Thu, 06 Aug 2009 07:43:00 EST<b>Form #:</b> CMS 728<br /><b>Form Title:</b> CMS Staff Data<br /><b>Revision Date:</b> 09/01/1994<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006607http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006607Thu, 06 Aug 2009 07:43:00 EST<b>Form #:</b> CMS 726<br /><b>Form Title:</b> CMS Death Record Review Data Sheet<br /><b>Revision Date:</b> 09/01/1994<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006615http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006615Thu, 06 Aug 2009 07:43:00 EST<b>Form #:</b> CMS 729<br /><b>Form Title:</b> Data Collection Medical Staff Coverage<br /><b>Revision Date:</b> 09/01/1994<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006611http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006611Thu, 06 Aug 2009 07:43:00 EST<b>Form #:</b> CMS 727<br /><b>Form Title:</b> CMS Nursing Complement Data<br /><b>Revision Date:</b> 09/01/1994<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008840http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008840Thu, 06 Aug 2009 07:44:00 EST<b>Form #:</b> CMS 209<br /><b>Form Title:</b> LABORATORY PERSONNEL REPORT (CLIA)<br /><b>Revision Date:</b> 09/01/1992<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012196http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012196Thu, 06 Aug 2009 07:44:00 EST<b>Form #:</b> CMS 1561<br /><b>Form Title:</b> HEALTH INSURANCE BENEFIT AGREEMENT<br /><b>Revision Date:</b> 07/01/2001<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019485http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019485Thu, 06 Aug 2009 07:44:00 EST<b>Form #:</b> CMS 1561A<br /><b>Form Title:</b> HEALTH INSURANCE BENEFIT AGREEMENT-RURAL HEALTH CLINIC<br /><b>Revision Date:</b> 04/01/2002<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019494http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019494Thu, 06 Aug 2009 07:44:00 EST<b>Form #:</b> CMS 1984<br /><b>Form Title:</b> HOSPICE COST REPORT<br /><b>Revision Date:</b> 02/01/2005<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006700http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006700Thu, 06 Aug 2009 07:45:00 EST<b>Form #:</b> CMS 854<br /><b>Form Title:</b> Certificate of Medical Necessity - DME 11.02<br /><b>Revision Date:</b> 09/30/2005<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006684http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006684Thu, 06 Aug 2009 07:45:00 EST<b>Form #:</b> CMS 848<br /><b>Form Title:</b> Certificate of Medical Necessity - Transcutaneous Electrical Nerve Stimulator (TENS) - DME 06.03B<br /><b>Revision Date:</b> 09/30/2005<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006677http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006677Thu, 06 Aug 2009 07:45:00 EST<b>Form #:</b> CMS 847<br /><b>Form Title:</b> Certificate of Medical Necessity - Osteogenesis Stimulators - DME 04.04C<br /><b>Revision Date:</b> 09/30/2005<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006687http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006687Thu, 06 Aug 2009 07:45:00 EST<b>Form #:</b> CMS 849<br /><b>Form Title:</b> Certificate of Medical Necessity - Seat Lift Mechanisms - DME 07.03A<br /><b>Revision Date:</b> 09/30/2005<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006674http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006674Thu, 06 Aug 2009 07:46:00 EST<b>Form #:</b> CMS 846<br /><b>Form Title:</b> Certificate of Medical Necessity - Pneumatic Compression Devices DME 04.04B<br /><b>Revision Date:</b> 09/30/2005<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012207http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012207Thu, 06 Aug 2009 07:46:00 EST<b>Form #:</b> CMS 1696<br /><b>Form Title:</b> APPOINTMENT OF REPRESENTATIVE<br /><b>Revision Date:</b> 07/01/2005<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS1207289http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS1207289Thu, 06 Aug 2009 13:34:00 EST<b>Form #:</b> CMS 10095DENC<br /><b>Form Title:</b> Detailed Explanation of Non-Ceverage<br /><b>Revision Date:</b> 12/01/2006<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS020275http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS020275Thu, 06 Aug 2009 13:37:00 EST<b>Form #:</b> CMS 10095NOMNC<br /><b>Form Title:</b> NOTICE OF MEDICARE NON-COVERAGE<br /><b>Revision Date:</b> 12/01/2006<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008825http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008825Wed, 12 Aug 2009 10:48:00 EST<b>Form #:</b> CMS 3427<br /><b>Form Title:</b> ESRD APPLICATION/NOTIFICATION AND SURVEY/CERTIFICATION REPORT<br /><b>Revision Date:</b> 06/01/1997<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS020294http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS020294Mon, 17 Aug 2009 10:13:00 EST<b>Form #:</b> CMS 417<br /><b>Form Title:</b> HOSPICE REQUEST FOR CERTIFICATION IN MEDICARE<br /><b>Revision Date:</b> 04/01/1984<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006741http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006741Tue, 18 Aug 2009 10:36:00 EST<b>Form #:</b> CMS 437A<br /><b>Form Title:</b> REHAB UNIT CRITERIA WORKSHEET<br /><b>Revision Date:</b> 03/01/2006<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006760http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006760Tue, 18 Aug 2009 10:36:00 EST<b>Form #:</b> CMS 437B<br /><b>Form Title:</b> REHAB HOSPITAL CRITERIA WORKSHEET<br /><b>Revision Date:</b> 03/01/2006<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012476http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012476Tue, 01 Sep 2009 08:10:00 EST<b>Form #:</b> CMS 10130B<br /><b>Form Title:</b> Request for Section 1011 Hospital On-Call Payments to Physicians<br /><b>Revision Date:</b> 05/01/2005<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012481http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012481Tue, 01 Sep 2009 08:10:00 EST<b>Form #:</b> CMS 10130A<br /><b>Form Title:</b> Section 1011 Provider Payment Determination<br /><b>Revision Date:</b> 01/01/2006<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS1215291http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS1215291Tue, 01 Sep 2009 08:11:00 EST<b>Form #:</b> CMS 10164<br /><b>Form Title:</b> Centers for Medicare and Medicaid Services EDI Registration Form; and EDI Enrollment Form<br /><b>Revision Date:</b> 03/01/2006<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019478http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019478Tue, 01 Sep 2009 08:15:00 EST<b>Form #:</b> CMS 855R<br /><b>Form Title:</b> Medicare Enrollment Application - Reassignment of Medicare Benefits<br /><b>Revision Date:</b> 02/01/2008<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019475http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019475Tue, 01 Sep 2009 08:15:00 EST<b>Form #:</b> CMS 855A<br /><b>Form Title:</b> Medicare Enrollment Application - Institutional Providers<br /><b>Revision Date:</b> 02/01/2008<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019520http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019520Tue, 01 Sep 2009 08:16:00 EST<b>Form #:</b> CMS 10124<br /><b>Form Title:</b> EXPEDITED REVIEW NOTICE-DETAILED EXPLANATION OF NON-COVERAGE<br /><b>Revision Date:</b> 02/29/2008<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019476http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019476Tue, 01 Sep 2009 08:16:00 EST<b>Form #:</b> CMS 855B<br /><b>Form Title:</b> Medicare Enrollment Application - Clinics/Group Practices and Certain Other Suppliers<br /><b>Revision Date:</b> 02/01/2008<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019477http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019477Tue, 01 Sep 2009 08:16:00 EST<b>Form #:</b> CMS 855I<br /><b>Form Title:</b> Medicare Enrollment Application - Physicians and Non-Physician Practitioners<br /><b>Revision Date:</b> 02/01/2008<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS1198447http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS1198447Tue, 01 Sep 2009 08:16:00 EST<b>Form #:</b> CMS 10198<br /><b>Form Title:</b> Creditable Coverage Disclosure to CMS On-line Form and Instructions<br /><b>Revision Date:</b> 02/01/2007<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019517http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019517Tue, 01 Sep 2009 08:17:00 EST<b>Form #:</b> CMS 10123<br /><b>Form Title:</b> EXPEDITED REVIEW NOTICE-NOTICE OF MEDICARE PROVIDER NON-COVERAGE<br /><b>Revision Date:</b> 02/29/2008<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019480http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019480Fri, 18 Sep 2009 11:08:00 EST<b>Form #:</b> CMS 855S<br /><b>Form Title:</b> Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers<br /><b>Revision Date:</b> 03/01/2009<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012932http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012932Wed, 23 Sep 2009 14:59:00 EST<b>Form #:</b> CMS R-131<br /><b>Form Title:</b> ADVANCE BENEFICIARY NOTICE (ABN)<br /><b>Revision Date:</b> 06/01/2002<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS013088http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS013088Mon, 05 Oct 2009 07:13:00 EST<b>Form #:</b> CMS 1771<br /><b>Form Title:</b> ATTENDING PHYSICIANS STATEMENT AND DOCUMENTATION FOR MEDICARE EMERGENCY<br /><b>Revision Date:</b> 09/01/1977<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019505http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019505Mon, 05 Oct 2009 07:14:00 EST<b>Form #:</b> CMS 2552-96<br /><b>Form Title:</b> COST REPORT FOR ELECTRONIC FILING OF HOSPITALS<br /><b>Revision Date:</b> 05/01/2004<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019164http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019164Mon, 05 Oct 2009 07:15:00 EST<b>Form #:</b> CMS 222<br /><b>Form Title:</b> INDEPENDENT RURAL HEALTH CLINIC WORKSHEET<br /><b>Revision Date:</b> 01/01/2005<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019162http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019162Mon, 05 Oct 2009 07:15:00 EST<b>Form #:</b> CMS 216<br /><b>Form Title:</b> ORGAN PROCUREMENT ORGANIZATION-HISTO-COMPATIBILITY LAB STATEMENT OF REIMBURSABLE COSTS<br /><b>Revision Date:</b> 11/01/2005<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019459http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019459Mon, 05 Oct 2009 07:16:00 EST<b>Form #:</b> CMS 287<br /><b>Form Title:</b> HOME OFFICE COST STATEMENT<br /><b>Revision Date:</b> 11/01/1995<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008727http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008727Mon, 05 Oct 2009 07:17:00 EST<b>Form #:</b> CMS 378<br /><b>Form Title:</b> AMBULATORY SURGICAL CENTER SURVEY REPORT<br /><b>Revision Date:</b> 01/01/1997<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008718http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008718Mon, 05 Oct 2009 07:20:00 EST<b>Form #:</b> CMS 377<br /><b>Form Title:</b> AMBULATORY SURGICAL CENTER REQUEST FOR CERTIFICATION IN MEDICARE<br /><b>Revision Date:</b> 01/01/1997<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008717http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008717Mon, 05 Oct 2009 07:21:00 EST<b>Form #:</b> CMS 370<br /><b>Form Title:</b> HEALTH INSURANCE BENEFITS AGREEMENT-AMBULATORY SURGICAL CENTER<br /><b>Revision Date:</b> 04/01/2002<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS007682http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS007682Mon, 05 Oct 2009 07:22:00 EST<b>Form #:</b> CMS 484<br /><b>Form Title:</b> CERTIFICATE OF MEDICAL NECESSITY - Oxygen DME 484.03<br /><b>Revision Date:</b> 09/30/2005<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008807http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008807Mon, 05 Oct 2009 07:22:00 EST<b>Form #:</b> CMS 382<br /><b>Form Title:</b> ESRD BENEFICIARY SELECTION<br /><b>Revision Date:</b> 01/01/2005<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006165http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006165Mon, 05 Oct 2009 07:25:00 EST<b>Form #:</b> CMS 562<br /><b>Form Title:</b> Medicare/Medicaid/CLIA Complaint Form<br /><b>Revision Date:</b> 01/01/1993<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006198http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006198Mon, 05 Oct 2009 07:26:00 EST<b>Form #:</b> CMS 588<br /><b>Form Title:</b> Electronic Funds Transfer (EFT) Authorization Agreement<br /><b>Revision Date:</b> 08/31/2006<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006189http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006189Mon, 05 Oct 2009 07:26:00 EST<b>Form #:</b> CMS 576A<br /><b>Form Title:</b> Health Insurance Benefits Agreement with Organ Procurement Organization<br /><b>Revision Date:</b> 06/29/2006<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006171http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006171Mon, 05 Oct 2009 07:26:00 EST<b>Form #:</b> CMS 576<br /><b>Form Title:</b> Organ Procurement Request for Designation as an OPO<br /><b>Revision Date:</b> 01/01/1993<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008870http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008870Mon, 05 Oct 2009 07:32:00 EST<b>Form #:</b> CMS 2786M<br /><b>Form Title:</b> FIRE SAFETY SURVEY - RATING RESIDENTS - 2000 CODE<br /><b>Revision Date:</b> 03/01/2004<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008869http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008869Mon, 05 Oct 2009 07:32:00 EST<b>Form #:</b> CMS 2746<br /><b>Form Title:</b> ESRD DEATH NOTIFICATION<br /><b>Revision Date:</b> 08/01/2006<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006581http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006581Mon, 05 Oct 2009 07:32:00 EST<b>Form #:</b> CMS 671<br /><b>Form Title:</b> LTC Facility Application for Medicare/Medicaid<br /><b>Revision Date:</b> 12/01/2002<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008829http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008829Mon, 05 Oct 2009 07:39:00 EST<b>Form #:</b> CMS 3509<br /><b>Form Title:</b> ALJ MEDICARE CASE FOLDER (CMS)<br /><b>Revision Date:</b> 08/02/2002<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008821http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008821Mon, 05 Oct 2009 07:39:00 EST<b>Form #:</b> CMS 3070I<br /><b>Form Title:</b> INDIVIDUAL OBSERVATION WORKSHEET<br /><b>Revision Date:</b> 10/01/1995<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008867http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008867Mon, 05 Oct 2009 07:39:00 EST<b>Form #:</b> CMS 2728<br /><b>Form Title:</b> ESRD MEDICAL EVIDENCE REPORT MEDICARE ENTITLEMENT AND/OR PATIENT REGISTRATION<br /><b>Revision Date:</b> 06/01/2004<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009406http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009406Mon, 05 Oct 2009 07:43:00 EST<b>Form #:</b> CMS 2802<br /><b>Form Title:</b> REQUEST FOR VALIDATION OF ACCREDITATION<br /><b>Revision Date:</b> 12/01/2001<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009506http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009506Mon, 05 Oct 2009 07:44:00 EST<b>Form #:</b> CMS 2802C<br /><b>Form Title:</b> REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR HOME HEALTH AGENCY<br /><b>Revision Date:</b> 01/01/2002<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008815http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008815Mon, 05 Oct 2009 07:44:00 EST<b>Form #:</b> CMS 3070G<br /><b>Form Title:</b> ICF/MR SURVEY REPORT<br /><b>Revision Date:</b> 03/01/2001<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009494http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009494Mon, 05 Oct 2009 07:44:00 EST<b>Form #:</b> CMS 2802B<br /><b>Form Title:</b> REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR HOSPICE<br /><b>Revision Date:</b> 01/01/2002<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008818http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008818Mon, 05 Oct 2009 07:44:00 EST<b>Form #:</b> CMS 3070H<br /><b>Form Title:</b> ICF/MR DEFICIENCIES REPORT<br /><b>Revision Date:</b> 11/01/2000<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009532http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009532Mon, 05 Oct 2009 07:47:00 EST<b>Form #:</b> CMS 2802E<br /><b>Form Title:</b> REQUEST FOR VALIDATION OF ACCREDITATION FOR CRITICAL ACCESS HOSPITAL SURVEY<br /><b>Revision Date:</b> 10/01/2003<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009514http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009514Mon, 05 Oct 2009 07:47:00 EST<b>Form #:</b> CMS 2802D<br /><b>Form Title:</b> REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR AMBULATORY SURGICAL CENTER<br /><b>Revision Date:</b> 01/01/2002<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009548http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009548Mon, 05 Oct 2009 08:01:00 EST<b>Form #:</b> CMS R-296<br /><b>Form Title:</b> HOME HEALTH ADVANCE BENEFICIARY NOTICE<br /><b>Revision Date:</b> 06/01/2002<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009561http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009561Mon, 05 Oct 2009 08:02:00 EST<b>Form #:</b> CMS 2501<br /><b>Form Title:</b> RECONSIDERATION DETERMINATION<br /><b>Revision Date:</b> 01/01/1972<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008803http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008803Mon, 05 Oct 2009 08:02:00 EST<b>Form #:</b> CMS 384<br /><b>Form Title:</b> QIO CASE SUMMARY<br /><b>Revision Date:</b> 03/01/1992<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009554http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009554Mon, 05 Oct 2009 08:02:00 EST<b>Form #:</b> CMS 2007<br /><b>Form Title:</b> PROVIDER TIE IN NOTICE<br /><b>Revision Date:</b> 03/01/1982<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009564http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009564Mon, 05 Oct 2009 08:03:00 EST<b>Form #:</b> CMS 2567B<br /><b>Form Title:</b> POST-CERTIFICATION REVISIT REPORT<br /><b>Revision Date:</b> 09/01/1992<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009585http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009585Mon, 05 Oct 2009 08:04:00 EST<b>Form #:</b> CMS 2878<br /><b>Form Title:</b> ACCREDITED HOSPITAL ALLEGATIONS REPORT<br /><b>Revision Date:</b> 04/01/1986<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009579http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009579Mon, 05 Oct 2009 08:04:00 EST<b>Form #:</b> CMS 2744A<br /><b>Form Title:</b> ESRD FACILITY SURVEY (DIALYSIS UNIT ONLY)<br /><b>Revision Date:</b> 07/14/2003<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS1199192http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS1199192Mon, 05 Oct 2009 08:04:00 EST<b>Form #:</b> CMS 383<br /><b>Form Title:</b> HEALTH INSURANCE CASE SUMMARY<br /><b>Revision Date:</b> 12/01/1982<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008795http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008795Mon, 05 Oct 2009 08:04:00 EST<b>Form #:</b> CMS 383<br /><b>Form Title:</b> HEALTH INSURANCE CASE SUMMARY<br /><b>Revision Date:</b> 12/01/1982<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009718http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS009718Mon, 05 Oct 2009 08:05:00 EST<b>Form #:</b> CMS L564<br /><b>Form Title:</b> Medicare Information<br /><b>Revision Date:</b> 04/01/2000<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS011709http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS011709Mon, 05 Oct 2009 08:06:00 EST<b>Form #:</b> CMS 1537C<br /><b>Form Title:</b> Medicare/Medicaid Hospital Swing-Bed Survey Report<br /><b>Revision Date:</b> 01/01/1992<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS011722http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS011722Mon, 05 Oct 2009 08:07:00 EST<b>Form #:</b> CMS 1539<br /><b>Form Title:</b> MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL<br /><b>Revision Date:</b> 07/01/1984<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012078http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012078Mon, 05 Oct 2009 08:09:00 EST<b>Form #:</b> CMS 1515B<br /><b>Form Title:</b> HOME HEALTH FUNCTIONAL ASSESSMENT INSTRUMENT: MODULE B<br /><b>Revision Date:</b> 06/01/1990<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012093http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012093Mon, 05 Oct 2009 08:10:00 EST<b>Form #:</b> CMS 1515C<br /><b>Form Title:</b> HOME HEALTH FUNCTIONAL ASSESSMENT MODULE C: HOME VISIT<br /><b>Revision Date:</b> 06/01/1990<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008716http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008716Mon, 05 Oct 2009 08:11:00 EST<b>Form #:</b> CMS 360<br /><b>Form Title:</b> CORF SURVEY REPORT<br /><b>Revision Date:</b> 12/01/2008<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012115http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012115Mon, 05 Oct 2009 08:12:00 EST<b>Form #:</b> CMS 1515E<br /><b>Form Title:</b> HOME HEALTH FUNCTION AND CARE SUMMARY: MODULE E<br /><b>Revision Date:</b> 06/01/1990<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008714http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008714Mon, 05 Oct 2009 08:12:00 EST<b>Form #:</b> CMS 359<br /><b>Form Title:</b> CORF REPORT FOR CERTIFICATION TO PARTICIPATE IN MEDICARE<br /><b>Revision Date:</b> 07/01/2003<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012104http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012104Mon, 05 Oct 2009 08:12:00 EST<b>Form #:</b> CMS 1515D<br /><b>Form Title:</b> HOME HEALTH FUNCTIONAL ASSESSMENT PATIENT CARE: MODULE D<br /><b>Revision Date:</b> 06/01/1990<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008696http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008696Mon, 05 Oct 2009 08:13:00 EST<b>Form #:</b> CMS 36P<br /><b>Form Title:</b> CONSENT FOR HOME VISIT FOR PACE SERVICES EVALUATION<br /><b>Revision Date:</b> 07/01/2002<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008698http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008698Mon, 05 Oct 2009 08:13:00 EST<b>Form #:</b> CMS 352<br /><b>Form Title:</b> PART A RECONSIDERATION INPUT RECORD<br /><b>Revision Date:</b> 06/01/1986<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012120http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012120Mon, 05 Oct 2009 08:13:00 EST<b>Form #:</b> CMS 1515F<br /><b>Form Title:</b> CALENDAR WORKSHEET - PRESCRIBED VISITS<br /><b>Revision Date:</b> 06/01/1990<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008711http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008711Mon, 05 Oct 2009 08:13:00 EST<b>Form #:</b> CMS 353<br /><b>Form Title:</b> PART A PREHEARING INPUT RECORD<br /><b>Revision Date:</b> 06/01/1986<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012203http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012203Mon, 05 Oct 2009 08:14:00 EST<b>Form #:</b> CMS 1572A<br /><b>Form Title:</b> HHA SURVEY AND DEFICIENCIES REPORT<br /><b>Revision Date:</b> 08/01/1990<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008682http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008682Mon, 05 Oct 2009 08:14:00 EST<b>Form #:</b> CMS 36<br /><b>Form Title:</b> CONSENT FOR HOME VISIT (English/Spanish)<br /><b>Revision Date:</b> 12/01/1990<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012447http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012447Mon, 05 Oct 2009 08:15:00 EST<b>Form #:</b> CMS 1563<br /><b>Form Title:</b> Monthly Intermediary Report on Medicare Secondary Payer Savings<br /><b>Revision Date:</b> 11/01/1997<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS007663http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS007663Mon, 05 Oct 2009 08:16:00 EST<b>Form #:</b> CMS 462L<br /><b>Form Title:</b> ADVERSE ACTI0N EXTRACT FOR SNFs AND NFs<br /><b>Revision Date:</b> 07/01/1995<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006389http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006389Mon, 05 Oct 2009 08:17:00 EST<b>Form #:</b> CMS 668B<br /><b>Form Title:</b> Post Lab Survey - CLIA<br /><b>Revision Date:</b> 07/01/2000<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006587http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006587Mon, 05 Oct 2009 08:18:00 EST<b>Form #:</b> CMS 673<br /><b>Form Title:</b> Extended/Partial Extended Survey Worksheet<br /><b>Revision Date:</b> 07/01/1995<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006598http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006598Mon, 05 Oct 2009 08:19:00 EST<b>Form #:</b> CMS 701<br /><b>Form Title:</b> Updated Plan of Progress for Outpatient Rehab<br /><b>Revision Date:</b> 11/01/1991<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006628http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006628Mon, 05 Oct 2009 08:19:00 EST<b>Form #:</b> CMS 805<br /><b>Form Title:</b> Resident Review Worksheet<br /><b>Revision Date:</b> 07/01/1995<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006583http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006583Mon, 05 Oct 2009 08:20:00 EST<b>Form #:</b> CMS 672<br /><b>Form Title:</b> Resident Census and Conditions of Residents<br /><b>Revision Date:</b> 10/01/1998<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS013110http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS013110Mon, 05 Oct 2009 08:20:00 EST<b>Form #:</b> CMS 1980<br /><b>Form Title:</b> CARRIER OR INTERMEDIARY REQUEST FOR SSO ASSISTANCE<br /><b>Revision Date:</b> 03/01/1978<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006623http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006623Mon, 05 Oct 2009 08:20:00 EST<b>Form #:</b> CMS 802S<br /><b>Form Title:</b> Roster/Sample Matrix Instruction for Surveyors<br /><b>Revision Date:</b> 05/01/2005<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006626http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006626Mon, 05 Oct 2009 08:23:00 EST<b>Form #:</b> CMS 804<br /><b>Form Title:</b> Kitchen/Food Service Observation<br /><b>Revision Date:</b> 07/01/1995<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006618http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006618Mon, 05 Oct 2009 08:23:00 EST<b>Form #:</b> CMS 801<br /><b>Form Title:</b> Offsite Survey Prep Worksheet<br /><b>Revision Date:</b> 07/01/1995<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS013094http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS013094Mon, 05 Oct 2009 08:26:00 EST<b>Form #:</b> CMS 1880<br /><b>Form Title:</b> REQUEST FOR CERTIFICATION AS SUPPLIER OF PORTABLE XRAY SERVICES<br /><b>Revision Date:</b> 10/01/1980<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006622http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006622Mon, 05 Oct 2009 08:26:00 EST<b>Form #:</b> CMS 802P<br /><b>Form Title:</b> Roster/Sample Matrix Provider Instructions<br /><b>Revision Date:</b> 05/01/2005<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS013075http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS013075Mon, 05 Oct 2009 08:27:00 EST<b>Form #:</b> CMS 1557<br /><b>Form Title:</b> SURVEY REPORT FORM - CLIA<br /><b>Revision Date:</b> 09/01/1992<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006620http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006620Mon, 05 Oct 2009 08:27:00 EST<b>Form #:</b> CMS 802<br /><b>Form Title:</b> Roster/Sample Matrix<br /><b>Revision Date:</b> 07/01/1999<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006631http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006631Mon, 05 Oct 2009 08:29:00 EST<b>Form #:</b> CMS 806B<br /><b>Form Title:</b> Quality of Life Assessment--Group<br /><b>Revision Date:</b> 07/01/1995<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS007754http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS007754Mon, 05 Oct 2009 08:29:00 EST<b>Form #:</b> CMS 462AB<br /><b>Form Title:</b> CLIA ADVERSE ACTION EXTRACT<br /><b>Revision Date:</b> 05/01/1997<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006634http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006634Mon, 05 Oct 2009 08:30:00 EST<b>Form #:</b> CMS 838<br /><b>Form Title:</b> Medicare Credit Balance Reporting Requirements<br /><b>Revision Date:</b> 10/01/2003<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006624http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006624Mon, 05 Oct 2009 08:30:00 EST<b>Form #:</b> CMS 803<br /><b>Form Title:</b> General Observations of Facility<br /><b>Revision Date:</b> 07/01/1995<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012220http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012220Mon, 05 Oct 2009 08:30:00 EST<b>Form #:</b> CMS 1882<br /><b>Form Title:</b> PORTABLE XRAY SURVEY REPORT<br /><b>Revision Date:</b> 03/01/1998<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS007566http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS007566Mon, 05 Oct 2009 08:31:00 EST<b>Form #:</b> CMS 460<br /><b>Form Title:</b> MEDICARE PARTICIPATING PHYSICIAN OR SUPPLIER AGREEMENT<br /><b>Revision Date:</b> 10/01/2005<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006591http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006591Mon, 05 Oct 2009 08:37:00 EST<b>Form #:</b> CMS 677<br /><b>Form Title:</b> Medication Pass Worksheet<br /><b>Revision Date:</b> 07/01/1995<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS013079http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS013079Mon, 05 Oct 2009 08:38:00 EST<b>Form #:</b> CMS 1564<br /><b>Form Title:</b> MONTHLY CARRIER REPORT ON MEDICARE SECONDARY PAYER SAVINGS<br /><b>Revision Date:</b> 11/01/1997<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012226http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012226Mon, 05 Oct 2009 08:38:00 EST<b>Form #:</b> CMS 1893<br /><b>Form Title:</b> OUTPATIENT PHYSICAL THERAPY - SPEECH PATHOLOGY SURVEY REPORT<br /><b>Revision Date:</b> 10/01/1999<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006629http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006629Mon, 05 Oct 2009 08:38:00 EST<b>Form #:</b> CMS 806A<br /><b>Form Title:</b> Quality of Life Assessment--Resident<br /><b>Revision Date:</b> 07/01/1995<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006595http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006595Mon, 05 Oct 2009 08:38:00 EST<b>Form #:</b> CMS 700<br /><b>Form Title:</b> Plan of Treatment for Outpatient Rehab<br /><b>Revision Date:</b> 11/01/1991<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS013105http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS013105Mon, 05 Oct 2009 08:38:00 EST<b>Form #:</b> CMS 1965<br /><b>Form Title:</b> REQUEST FOR HEARING - PART B MEDICARE CLAIM<br /><b>Revision Date:</b> 05/01/2003<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS013081http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS013081Mon, 05 Oct 2009 08:43:00 EST<b>Form #:</b> CMS 1666<br /><b>Form Title:</b> REGIONAL OFFICE REQUEST FOR ADDITIONAL INFORMATION<br /><b>Revision Date:</b> 04/01/1980<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS1193148http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS1193148Mon, 05 Oct 2009 08:44:00 EST<b>Form #:</b> CMS 10106<br /><b>Form Title:</b> 1-800-Medicare Authorization to Disclosure Personal Health Information<br /><b>Revision Date:</b> 04/01/2008<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS007776http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS007776Mon, 05 Oct 2009 08:45:00 EST<b>Form #:</b> CMS 4040<br /><b>Form Title:</b> REQUEST FOR ENROLLMENT IN SUPPLEMENTARY MEDICAL INSURANCE (English / Spanish)<br /><b>Revision Date:</b> 08/01/1991<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006633http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006633Mon, 05 Oct 2009 08:45:00 EST<b>Form #:</b> CMS 807<br /><b>Form Title:</b> Surveyor Notes Worksheet<br /><b>Revision Date:</b> 07/01/1995<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012215http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012215Mon, 05 Oct 2009 08:45:00 EST<b>Form #:</b> CMS 1856<br /><b>Form Title:</b> Request for Certification in the Medicare and/or Medicaid Program to Provide Outpatient Physical Therapy and/or Speech Pathology Services<br /><b>Revision Date:</b> 12/11/2006<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006632http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006632Mon, 05 Oct 2009 08:45:00 EST<b>Form #:</b> CMS 806C<br /><b>Form Title:</b> Quality of Life Assessment--Family<br /><b>Revision Date:</b> 07/01/1995<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006712http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS006712Mon, 05 Oct 2009 08:45:00 EST<b>Form #:</b> CMS 437<br /><b>Form Title:</b> PSYCHIATRIC UNIT CRITERIA WORKSHEET<br /><b>Revision Date:</b> 04/01/1990<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012996http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012996Mon, 05 Oct 2009 08:46:00 EST<b>Form #:</b> CMS 1541A<br /><b>Form Title:</b> RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN EMERGENCY CASES<br /><b>Revision Date:</b> 04/01/1995<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS013070http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS013070Mon, 05 Oct 2009 08:46:00 EST<b>Form #:</b> CMS 1541B<br /><b>Form Title:</b> RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN EMERGENCY CASES INVESTIGATION REPORT<br /><b>Revision Date:</b> 04/01/1995<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS013099http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS013099Mon, 05 Oct 2009 08:46:00 EST<b>Form #:</b> CMS 1938<br /><b>Form Title:</b> SSO REQUEST FOR CARRIER/INTERMEDIARY ASSISTANCE<br /><b>Revision Date:</b> 01/01/1988<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012941http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012941Mon, 19 Oct 2009 12:10:00 EST<b>Form #:</b> CMS R-193<br /><b>Form Title:</b> IMPORTANT MESSAGE FROM MEDICARE (IM)<br /><b>Revision Date:</b> 10/01/2007<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS1189117http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS1189117Wed, 21 Oct 2009 06:15:00 EST<b>Form #:</b> CMS 10069<br /><b>Form Title:</b> Medicare Waiver Demonstration Application<br /><b>Revision Date:</b> 08/01/2006<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019489http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS019489Wed, 21 Oct 2009 06:16:00 EST<b>Form #:</b> CMS 1728<br /><b>Form Title:</b> HOME HEALTH AGENCY COST REPORT<br /><b>Revision Date:</b> 06/01/2001<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS1188854http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS1188854Wed, 21 Oct 2009 06:16:00 EST<b>Form #:</b> CMS 1500<br /><b>Form Title:</b> Health Insurance Claim Form<br /><b>Revision Date:</b> 08/01/2005<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012182http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012182Wed, 21 Oct 2009 06:17:00 EST<b>Form #:</b> CMS 179<br /><b>Form Title:</b> TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL<br /><b>Revision Date:</b> 07/01/1992<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS017342http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS017342Wed, 21 Oct 2009 06:18:00 EST<b>Form #:</b> CMS 43<br /><b>Form Title:</b> APPLICATION FOR HEALTH INSURANCE UNDER MEDICARE FOR INDIVIDUAL WITH CHRONIC RENAL DISEASE<br /><b>Revision Date:</b> 08/01/1981<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS013118http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS013118Wed, 21 Oct 2009 06:22:00 EST<b>Form #:</b> CMS 10114<br /><b>Form Title:</b> NATIONAL PROVIDER IDENTIFIER (NPI) APPLICATION/UPDATE FORM<br /><b>Revision Date:</b> 11/01/2008<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS060878http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS060878Mon, 16 Nov 2009 14:34:00 EST<b>Form #:</b> CMS R-285<br /><b>Form Title:</b> Request for Retirement Benefit Information<br /><b>Revision Date:</b> 03/01/2006<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS054015http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS054015Mon, 16 Nov 2009 14:42:00 EST<b>Form #:</b> CMS R-0235D1<br /><b>Form Title:</b> DSH Data Use Agreement<br /><b>Revision Date:</b> 03/01/2008<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS060914http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS060914Mon, 16 Nov 2009 14:43:00 EST<b>Form #:</b> CMS R-0235ST<br /><b>Form Title:</b> State Data Use Agreement<br /><b>Revision Date:</b> 03/01/2006<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS045948http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS045948Mon, 16 Nov 2009 14:43:00 EST<b>Form #:</b> CMS R-0235U (48 KB)<br /><b>Form Title:</b> Data Use Agreement (DUA)- Update to Existing DUA<br /><b>Revision Date:</b> 06/01/2008<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS055728http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS055728Mon, 16 Nov 2009 14:43:00 EST<b>Form #:</b> CMS R-0235D2<br /><b>Form Title:</b> DSH Data Use Agreement for Cost Reporting Periods That Include December 8, 2004 and Thereafter<br /><b>Revision Date:</b> 03/01/2008<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS045945http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS045945Mon, 16 Nov 2009 14:43:00 EST<b>Form #:</b> CMS R-0235L (64 KB)<br /><b>Form Title:</b> Data Use Agreement (DUA)- Limited Data Sets<br /><b>Revision Date:</b> 02/01/2008<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS1207001http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS1207001Mon, 16 Nov 2009 14:44:00 EST<b>Form #:</b> CMS 10221<br /><b>Form Title:</b> Independent Diagnostic Testing Facilities-Site Investigation<br /><b>Revision Date:</b> 12/01/2007<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012169http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012169Mon, 16 Nov 2009 14:44:00 EST<b>Form #:</b> CMS 116<br /><b>Form Title:</b> CLINICAL LABORATORY IMPROVEMENT AMENDMENTS OF 1988 (CLIA) APPLICATION FOR CERTIFICATION<br /><b>Revision Date:</b> 10/01/2007<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS013121http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS013121Mon, 16 Nov 2009 14:44:00 EST<b>Form #:</b> CMS 10115<br /><b>Form Title:</b> SECTION 1011 PROVIDER ENROLLMENT APPLICATION<br /><b>Revision Date:</b> 10/01/2008<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008787http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS008787Mon, 16 Nov 2009 14:44:00 EST<b>Form #:</b> CMS 381<br /><b>Form Title:</b> MODEL LETTER REQUESTING IDENTIFICATION OF EXTENSION LOCATIONS<br /><b>Revision Date:</b> 12/01/2005<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS060976http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS060976Mon, 16 Nov 2009 14:44:00 EST<b>Form #:</b> CMS R-0235MC<br /><b>Form Title:</b> Compliance Plan for Accounting for Disclosures of Privacy Protected Data Released From a System of Records (SOR) Housed in a State-Located Server<br /><b>Revision Date:</b> 03/01/2006<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS045942http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS045942Mon, 16 Nov 2009 14:45:00 EST<b>Form #:</b> CMS R-0235A (35 KB)<br /><b>Form Title:</b> Addendum to Data Use Agreement (DUA)<br /><b>Revision Date:</b> 03/01/2006<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS057714http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS057714Mon, 16 Nov 2009 14:45:00 EST<b>Form #:</b> CMS R-0235MA<br /><b>Form Title:</b> Addendum to the Medicaid State Agency Data Use Agreement<br /><b>Revision Date:</b> 03/01/2006<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS045932http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS045932Mon, 16 Nov 2009 14:45:00 EST<b>Form #:</b> CMS R-0235 (66 KB)<br /><b>Form Title:</b> Data Use Agreement (DUA) (Agreement for use of Centers for Medicare and Medicaid Services (CMS) data containing individual-specific information<br /><b>Revision Date:</b> 05/01/2008<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS057233http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS057233Mon, 16 Nov 2009 14:45:00 EST<b>Form #:</b> CMS R-0235M<br /><b>Form Title:</b> Medicaid Agency Data Use Agreement<br /><b>Revision Date:</b> 03/01/2006<br />http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012949http://www.cms.hhs.gov/CMSForms/CMSForms/ItemDetail.asp?ItemID=CMS012949Fri, 20 Nov 2009 16:02:00 EST<b>Form #:</b> CMS 1490S<br /><b>Form Title:</b> PATIENT'S REQUEST FOR MEDICAL PAYMENT (English/Spanish)<br /><b>Revision Date:</b> 01/01/2005<br />