Forms

This is a collection of commonly used Medicare forms. Many of the forms on this page are reached through external links to the CMS Web site

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Appeals Forms

• Medicare Redetermination Request (CMS 20027)
• Medicare Reconsideration Request (CMS 20033)
• NHIC, Corp. Reopening-Redetermination Request Form
• Request for Medicare Hearing by an ALJ (CMS 20034A/B)
• Transfer (Assignment) of Appeal Rights (CMS 20031)

Electronic Data Interchange (EDI) Forms

For details and instructions on how to complete the forms, please refer to the EDI Enrollment Forms page.

• EDI Enrollment Forms– forms required for first time Enrollment in EDI
• Electronic Remittance Advice (ERA) Enrollment Form – for providers who bill NHIC Corp. Medicare Part B directly and wish to receive their ERA files
• Provider / Submitter Agreement for ERA Form – used for changing enrollment and/or adding ERA with the change, or adding ERA to an existing enrollment
• Provider / Separate Remittance Agreement Form – special use form see the ERA section of the Enrollment Forms page for details

Provider Enrollment Forms

• 855B - Application for Health Care Suppliers that will Bill Medicare Carriers (CMS 855B)
• 855I - Application for Individual Practitioners (CMS 855I)
• 855R - Application for Reassignment of Benefits (CMS 855R)
• Electronic Funds Transfer Authorization (CMS 588)
• Medicare Participating Physician or Supplier (CMS 460)

Roster Billing Forms

NHIC Inquiry Forms

• NHIC, Corp. Part B Written Inquiries Form
  Use this form if you have general questions about topics such as Medicare coverage, billing information or clarification on Medicare policy.
• NHIC Part B Website Feedback form
  Use this form if you have issues related to NHIC's Medicare website (broken links, navigation, suggestions, etc.).

Other CMS Forms

• CMS 1500 Health Insurance Claim Form (08-05) 
• Advance Beneficiary Notice (ABN) Form (CMS-R-131)
• Notice of Exclusions from Medicare Benefits (NEMB) Form (CMS-20007)
• Complete CMS Forms Listing

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Medical Review

• Consultation Dual Documentation Request Form
• Medical Review Reopening Request Form

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01/28/2010