Forms

  • Electronic File Interchange Organization (EFIO) Certification Statement
  • Independent Diagnostic Testing Facilities-Site Investigation
  • Data Use Agreement (DUA) Certficate Of Disposition (COD) For Data Acquired From The Centers For Medicare & Medicaid Services (CMS)
  • Medicare Quality of Care Complaint Form
  • Clinical Laboratory Improvement Amendments Of 1988 (ClIA) Application For Certification
  • Health Insurance Claim Form
  • Medicare/Medicaid Certification and Transmittal
  • Responsibilities of Medicare Participating Hospitals In Emergency Cases Investigation Report
  • Health Insurance Benefit Agreement
  • Health Insurance Benefit Agreement-Rural Health Clinic
  • Monthly Intermediary Report on Medicare Secondary Payer Savings
  • Monthly Carrier Report on Medicare Secondary Payer Savings
  • HHA Survey and Deficiencies Report
  • Regional Office Request For Additional Information
  • Appointment of Representative
  • Attending Physicians Statement and Documentation For Medicare Emergency
  • Transmittal and Notice of Approval Of State Plan Material
  • Request for Certification in the Medicare and/or Medicaid Program to Provide Outpatient Physical Therapy and/or Speech Pathology Services
  • Portable Xray Survey Report
  • Outpatient Physical Therapy - Speech Pathology Survey Report
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