Forms

  • Certificate of Medical Necessity - Transcutaneous Electrical Nerve Stimulator (TENS) - DME 06.03B
  • Certificate of Medical Necessity - Seat Lift Mechanisms - DME 07.03A
  • Certificate of Medical Necessity - DME 11.02
  • Medicare Enrollment Application - Institutional Providers
  • Medicare Enrollment Application - Clinics/Group Practices and Certain Other Suppliers
  • Medicare Enrollment Application - Registration For Eligible Ordering and Referring Physicians and Non-Physician Practitioners
  • Data Use Agreement (DUA) Addendum For Data Acquired From The Centers For Medicare &Amp; Medicaid Services (CMS)
  • Addendum to Data Use Agreement (DUA)
  • Compliance Plan for Accounting for Disclosures of Privacy Protected Data Released From a System of Records (SOR) Housed in a State-Located Server
  • Data Use Agreement
  • Data Use Agreement Update To Existing Data Use Agreement
  • Request For Retirement Benefit Information
  • Report of a Hospital Death Associated with Restrain or Seclusion
  • DSH Data Use Agreement for Cost Reporting Periods Prior to those that include December 8, 2004
  • DSH Data Use Agreement for Cost Reporting Periods that Include December 8, 2004
  • DSH Data Use Agreement for Cost Reporting Periods that Include December 8, 2004 and therafter
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