Forms

The forms listed on this page are taken from the Medicare website forms section and are the forms that a chiropractor will need access to.

Enrollment Forms

CMS-10114  This form is used to apply for a National Provider Identifier (NPI)

CMS-855i  This form is used to enroll individual doctors in Medicare.

CMS-855b  This form is used to enroll a business entity (such as a corporation or partnership) in Medicare.

CMS-855r  This form is used by the doctor to reassign his right to be paid to a business entity (such as a corporation or partnership).  It is also used by associates to reassign their right to be paid to their employer.  Click here to read an alert issued by the OIG regarding the use of this form.

CMS-588  This form is used to set up the Electronic Funds Transfer agreement with Medicare.  Click here to read about a special precaution that you must employ with the use of this form.

CMS-460  This form is used to become a Medicare Participating Provider.

CMS-10164A  This is the Electronic Data Interchange Registration form.

CMS-10164B  This is the Electronic Data Interchange Enrollment form.

 

Appeals

CMS-20027  This form is used to request a Redetermination, which is the first level of appeal.

CMS-20033  This form is used to request a reconsideration, which is the second level of appeal.

CMS-20034AB  This form is used to request a hearing before an Administrative Law Judge, which is the third level of appeal.  Click here to view Medicare web page on “What You Need To Know To Request A Hearing Before An Administrative Law Judge”.

CMS-1696  This from is used to appoint a representative (attorney) for an appeal to an Administrative Law Judge.

CMS-20031  This form is used to assign (transfer) the appeal rights from the Medicare beneficiary to the doctor when necessary.

 

ABN

Advance Beneficiary Notification of Non-Coverage English Version (ABN) This form is used to inform a Medicare patient of their potential financial liability.

Non-Par Advance Beneficiary Notification of Non-Coverage English Version (Non-Par ABN) This form has special language added that is required by Medicare for non participating doctors to inform a Medicare patient of their potential financial liability.

Advance Beneficiary Notification of Non-Coverage Spanish Version (ABN) This form is used to inform a Spanish speaking Medicare patient of their potential financial liability.

ABN Form Instructions The official instructions for completing the ABN

 

Lab

CMS-116  This form is used to apply for CLIA Waived Certification.

 

Diagnosis

Universal Medicare Diagnosis List  This is a listing of Medicare diagnoses that are accepted in all states and territories.

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