CMS Forms: PDFs, Instructions & Fax Numbers

CMS forms guide: open official PDFs, instructions, agency source links, and filing-method notes before you prepare or fax a document.

CMS Form Guides

Open the detail pages below for official PDF references, source-page context, and related form links for this agency.

Indexed Form Guides

CMS 10036: Inpatient Rehabilitation Facility-Patient Assessment Instrument
Read the guide for CMS 10036, then open the official filing resources from the detail page.
CMS 10069: Medicare Waiver Demonstration Application
Read the guide for CMS 10069, then open the official filing resources from the detail page.
CMS 10106 PDF: 1-800-Medicare Authorization to Disclosure Personal Health Information
Read the guide for CMS 10106 PDF, then open the official filing resources from the detail page.
CMS 10114: NATIONAL PROVIDER IDENTIFIER (NPI) APPLICATION/UPDATE FORM
Read the guide for CMS 10114, then open the official filing resources from the detail page.
CMS 10125: DME Information Form - External Infusion Pumps DME 09.03
Read the guide for CMS 10125, then open the official filing resources from the detail page.
CMS 10126: DME Information Form - Enteral and Parenteral Nutrition DME 10.03
Read the guide for CMS 10126, then open the official filing resources from the detail page.
CMS 10164: Centers for Medicare and Medicaid Services EDI Registration Form; and EDI Enrollment Form
Read the guide for CMS 10164, then open the official filing resources from the detail page.
CMS 10221: Independent Diagnostic Testing Facilities-Site Investigation
Read the guide for CMS 10221, then open the official filing resources from the detail page.
CMS 10252: DATA USE AGREEMENT (DUA) CERTFICATE OF DISPOSITION (COD) FOR DATA ACQUIRED FROM THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
Read the guide for CMS 10252, then open the official filing resources from the detail page.
CMS 10269: CMN Positive Airway Pressure (PAP)Devices for Obstructive Sleep Apnea
Read the guide for CMS 10269, then open the official filing resources from the detail page.
CMS 10287: Medicare Quality of Care Complaint Form
Read the guide for CMS 10287, then open the official filing resources from the detail page.
CMS-10455: Report of a Hospital Death Associated with Restraint or Seclusion
Read the guide for CMS-10455, then open the official filing resources from the detail page.
CMS 116: CLINICAL LABORATORY IMPROVEMENT AMENDMENTS OF 1988 (CLIA) APPLICATION FOR CERTIFICATION
Read the guide for CMS 116, then open the official filing resources from the detail page.
CMS 1490S: PATIENT'S REQUEST FOR MEDICAL PAYMENT (English/Spanish)
Read the guide for CMS 1490S, then open the official filing resources from the detail page.
CMS 1500: Health Insurance Claim Form
Read the guide for CMS 1500, then open the official filing resources from the detail page.
CMS 1539: MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL
Read the guide for CMS 1539, then open the official filing resources from the detail page.
CMS 1541B: RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN EMERGENCY CASES INVESTIGATION REPORT
Read the guide for CMS 1541B, then open the official filing resources from the detail page.
CMS 1557: SURVEY REPORT FORM - CLIA
Read the guide for CMS 1557, then open the official filing resources from the detail page.
CMS 1561: HEALTH INSURANCE BENEFIT AGREEMENT
Read the guide for CMS 1561, then open the official filing resources from the detail page.
CMS 1561A: HEALTH INSURANCE BENEFIT AGREEMENT-RURAL HEALTH CLINIC
Read the guide for CMS 1561A, then open the official filing resources from the detail page.
CMS 1563: Monthly Intermediary Report on Medicare Secondary Payer Savings
Read the guide for CMS 1563, then open the official filing resources from the detail page.
CMS 1564: MONTHLY CARRIER REPORT ON MEDICARE SECONDARY PAYER SAVINGS
Read the guide for CMS 1564, then open the official filing resources from the detail page.
CMS 1572: HHA SURVEY REPORT
Read the guide for CMS 1572, then open the official filing resources from the detail page.
CMS 1666: REGIONAL OFFICE REQUEST FOR ADDITIONAL INFORMATION
Read the guide for CMS 1666, then open the official filing resources from the detail page.
CMS 1696: APPOINTMENT OF REPRESENTATIVE
Read the guide for CMS 1696, then open the official filing resources from the detail page.
CMS 1763: Request for Termination of Premium Hospital Insurance of Supplementary Medical Insurance
Read the guide for CMS 1763, then open the official filing resources from the detail page.
CMS 1771: ATTENDING PHYSICIANS STATEMENT AND DOCUMENTATION FOR MEDICARE EMERGENCY
Read the guide for CMS 1771, then open the official filing resources from the detail page.
CMS 179: TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL
Read the guide for CMS 179, then open the official filing resources from the detail page.
CMS 18-F-5: Application for Medicare Part A (Hospital Insurance)
Read the guide for CMS 18-F-5, then open the official filing resources from the detail page.
CMS 1856: Request for Certification in the Medicare and/or Medicaid Program to Provide Outpatient Physical Therapy and/or Speech Pathology Services
Read the guide for CMS 1856, then open the official filing resources from the detail page.
CMS 1880: REQUEST FOR CERTIFICATION AS SUPPLIER OF PORTABLE XRAY SERVICES
Read the guide for CMS 1880, then open the official filing resources from the detail page.
CMS 1882: PORTABLE XRAY SURVEY REPORT
Read the guide for CMS 1882, then open the official filing resources from the detail page.
CMS 1957: SSO REPORT OF STATE BUY IN PROBLEM
Read the guide for CMS 1957, then open the official filing resources from the detail page.
CMS 1980: CARRIER OR INTERMEDIARY REQUEST FOR SSO ASSISTANCE
Read the guide for CMS 1980, then open the official filing resources from the detail page.
CMS 20017: ADVISORY PANEL ON HOSPITAL OUTPATIENT PAYMENT
Read the guide for CMS 20017, then open the official filing resources from the detail page.
CMS 20027: MEDICARE REDETERMINATION REQUEST FORM
Read the guide for CMS 20027, then open the official filing resources from the detail page.