Forms
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REQUEST FOR CERTIFICATION AS SUPPLIER OF PORTABLE XRAY SERVICES
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PATIENTS REQUEST FOR MEDICAL PAYMENT
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THIRD PARTY PREMIUM BILLING REQUEST, MEDICARE
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Medicare Enrollment Application - Medicare Diabetes Prevention Program (MDPP) Suppliers
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Notice of Denial of Medicare Prescription Drug Coverage English/Spanish
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NATIONAL PROVIDER IDENTIFIER (NPI) APPLICATION/UPDATE FORM
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Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers
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Medicare Enrollment Application - Reassignment of Medicare Benefits
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UB-04 Uniform Bill
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SKILLED NURSING FACILITY ADVANCED BENEFICIARY NOTICE
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Medicare Adminstration Observation
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FIRE SAFETY SURVEY REPORT 2000 CODE - HEALTH CARE - MEDICARE - MEDICAID
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Detailed Explanation of Non-Coverage
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Data Use Agreement (DUA)- Update to Existing DUA
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Data Use Agreement (DUA)- Limited Data Sets
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Data Use Agreement (DUA) (Agreement for use of Centers for Medicare and Medicaid Services (CMS) data containing individual-specific information
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CONSENT FOR HOME VISIT (English/Spanish)
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Centers for Medicare and Medicaid Services EDI Registration Form; and EDI Enrollment Form
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Annual Report of Physician-Owned Hospital Ownership and/or Investment Interest
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ADVISORY PANEL ON HOSPITAL OUTPATIENT PAYMENT