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Forms

Authorization to share protected health information -- Floridapdf file
Modified: 11/11/2010
The purpose of this authorization is to permit Medicare to release to a third party, specific Medicare records and or claim information.
Authorization to share protected health information -- Puerto Ricopdf file
Modified: 11/11/2010
The purpose of this authorization is to permit Medicare to release to a third party, specific Medicare records and or claim information.
Authorization to share protected health information -- U.S. Virgin Islandspdf file
Modified: 11/11/2010
The purpose of this authorization is to permit Medicare to release to a third party, specific Medicare records and or claim information.
CMS-1500 (08/05) paper claim form
Modified: 11/3/2011
Find information on where to obtain and how to complete the CMS 1500 claim form.
CMS-1696 form: Appointment of representativeexternal pdf file
Modified: 9/7/2010
This form is used by beneficiaries to authorize an individual to act as a representative in connection with a Medicare appeal.
CMS-460 Medicare Participating Physician or Supplier Agreementexternal pdf file
Modified: 10/17/2011
Participants agree to accept assignment for all covered services provided to Medicare patients. New physicians, practitioners, and suppliers may submit this form at the time of enrollment.
CMS’ Beneficiary Notices Initiative (BNI)
Modified: 1/19/2012
Learn about the Centers for Medicare & Medicaid Services’ (CMS) beneficiary notices initiative, including when and which types of notices should be used to inform beneficiaries of their financial liability, appeal rights, and protections. This article also includes links to current versions of the most commonly used beneficiary notices (e.g., Advanced Beneficiary Notice [ABN]).
CMS-855 Provider/supplier enrollment applications
Modified: 10/24/2011
Visit the provider enrollment applications page to determine which CMS-855 forms fit your enrollment needs.
Credit Balance Reporting Formsexternal pdf file
Modified: 12/22/2011
This report is required of the Social Security Act. Failure to submit this report may result in a suspension of payments under the Medicare program and may affect your eligibility to participate in the Medicare program.
Extended repayment schedule for corporation or group form
Modified: 1/5/2012
To consider an extended repayment schedule request for a corporation or group, the following documentation is required.
Extended repayment schedule for sole proprietor form
Modified: 1/5/2012
Sole proprietors who wish to request an extended repayment schedule request must complete an extended repayment schedule request form.
Forms page on CMS.govexternal link
Modified: 2/3/2012
The 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.
Influenza virus vaccine rosterpdf file
Modified: 1/22/2009
Here is a roster to use to capture patient information when creating an influenza virus vaccine roster.
Influenza virus vaccine: sample CMS-1500pdf file
Modified: 1/22/2009
Use this example of how to complete the CMS-1500 form when roster billing claims for influenza virus vaccine.
Medicare A Connection Subscription Formpdf file
Modified: 10/25/2011
Medicare A Connection Subscription Form
Overpayment reporting formpdf file
Modified: 12/22/2011
Please use this new interactive form when reporting overpayments. Provider must select option - if none is checked, an overpayment letter will be issued. Mail the completed form to the revised address included at the end of the form. [CR 3274]
Overpayment refund form -- Floridapdf file
Modified: 1/19/2012
Provider must select options. If none are checked, an overpayment letter will be issued. Mail the form to the appropriate address included at the bottom of the form.
Medicare Secondary Payer overpayment refund form -- Floridapdf file
Modified: 1/19/2012
Provider must select options. If none are checked, an overpayment letter will be issued. Mail the form to the appropriate address included at the bottom of the form.
Pneumococcal pneumonia virus vaccine: sample CMS-1500pdf file
Modified: 9/16/2011
Use this example of how to complete the CMS-1500 form when roster billing claims for pneumococcal pneumonia virus vaccine.
Pneumococcal pneumonia virus vaccine rosterpdf file
Modified: 1/22/2009
Here is a roster to use to capture patient information when creating a pneumococcal pneumonia virus vaccine roster.
Request for telephone clerical reopening formpdf file
Modified: 2/25/2011
Use this form to request a clerical reopening over the telephone. All related information must be completed on the form for the request to be honored.
Order form -- 2012 Part B materialspdf file
Modified: 1/31/2012
Items available for purchase are the 2012 fee schedule and an annual subscription to the Medicare B Connection!
Overpayment redetermination request form for a Medicare Part B claim for Floridapdf file
Modified: 3/14/2011
The "Request for Overpayment Redetermination of a Medicare Part B Claim" form simplifies and standardizes filing requirements for overpayment redeterminations.
Request for immediate offset formpdf file
Modified: 1/5/2012
Use this new interactive form when requesting immediate offset of overpayments. Fax the completed form to the number included within the form.
Request for immediate offset formpdf file
Modified: 12/22/2011
Use this new interactive form when requesting immediate offset of overpayments. Fax the completed form to the number included within the form.
Request for a redetermination of a Part A Medicare claim for Floridapdf file
Modified: 11/29/2010
This form is for an appeal and is not to be used when requesting a claim adjustment. Fill it out online, then print and mail it to the address indicated on the form.
Request for redetermination of a Part B claim for Floridapdf file
Modified: 11/29/2010
Minor clerical errors or omissions can be corrected more quickly outside of the formal appeal process. Use this interactive form to help ensure your request is processed accurately.
Reconsideration request form -- Maximus for Floridapdf file
Modified: 1/18/2012
If you wish to appeal the decision, fill out the required information form.
Reconsideration request form -- Q2 Administrators, LLC for Floridapdf file
Modified: 11/29/2010
This form is to be used for second-level appeals only. Please use the redetermination request form for a first-level appeal request. [CR 6285]
Medicare Secondary Payer overpayment refund form -- Puerto Ricopdf file
Modified: 1/19/2012
Provider must select options. If none are checked, an overpayment letter will be issued. Mail the form to the appropriate address included at the bottom of the form.
Medicare Secondary Payer overpayment refund form -- U.S. Virgin Islandspdf file
Modified: 1/19/2012
Provider must select options. If none are checked, an overpayment letter will be issued. Mail the form to the appropriate address included at the bottom of the form.
Overpayment refund form -- Puerto Ricopdf file
Modified: 1/19/2012
Provider must select options. If none are checked, an overpayment letter will be issued. Mail the form to the appropriate address included at the bottom of the form.
Overpayment redetermination request for a Medicare Part B claim for Puerto Ricopdf file
Modified: 3/14/2011
The "Overpayment redetermination request for a Medicare Part B claim" form simplifies and standardizes filing requirements for overpayment redeterminations.
Reconsideration request form -- Maximus for Puerto Ricopdf file
Modified: 1/18/2012
If you wish to appeal the decision, fill out the required information form.
Reconsideration request form -- Q2 Administrators, LLC for Puerto Ricopdf file
Modified: 11/29/2010
This form is to be used for second-level appeals only. Please use the redetermination request form for a first-level appeal request. [CR 6285]
Request for a redetermination of a Part A Medicare Claim for Puerto Ricopdf file
Modified: 11/29/2010
This form is for an appeal and is not to be used when requesting a claim adjustment. Fill it out online, then print and mail it to the address indicated on the form.
Request for redetermination of a Medicare Part B claim for Puerto Ricopdf file
Modified: 11/29/2010
Minor clerical errors or omissions can be corrected more quickly outside of the formal appeal process. Use this interactive form to help ensure your request is processed accurately.
Overpayment refund form -- U.S. Virgin Islandspdf file
Modified: 1/19/2012
Provider must select options. If none are checked, an overpayment letter will be issued. Mail the form to the appropriate address included at the bottom of the form.
Overpayment redetermination request for a Medicare Part B claim for U.S. Virgin Islandspdf file
Modified: 3/14/2011
The "Request for Overpayment Redetermination of a Medicare Part B Claim" form simplifies and standardizes filing requirements for overpayment redeterminations.
Reconsideration request form -- Maximus for U.S. Virgin Islandspdf file
Modified: 1/18/2012
If you wish to appeal the decision, fill out the required information form.
Reconsideration request form -- Q2 Administrators, LLC for U.S. Virgin Islandspdf file
Modified: 11/29/2010
This form is to be used for second-level appeals only. Please use the redetermination request form for a first-level appeal request. [CR 6285]
Request for a redetermination of a Part A Medicare claim for U.S. Virgin Islandspdf file
Modified: 11/29/2010
This form is for an appeal and is not to be used when requesting a claim adjustment. Fill it out online, then print and mail it to the address indicated on the form.
Request for redetermination of a Medicare Part B claim for U.S. Virgin Islandspdf file
Modified: 11/29/2010
Minor clerical errors or omissions can be corrected more quickly outside of the formal appeal process. Use this interactive form to help ensure your request is processed accurately.
First Coast Service Options (FCSO) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.