Healthcare Forms

IRS form provided by the Health Insurance Marketplace to report coverage information.

IRS form used by large employers to report health insurance coverage offered to employees.

Official CMS/Medicare authorization form to disclose personal health information.

CMS 1500 Claim Form for healthcare provider billing

Medicare authorization form allowing CMS to disclose a beneficiary personal health information to a selected person or organization.

Medicare beneficiary claim form used to request payment when a provider or supplier did not file a Medicare claim.

Medicare form used to request voluntary termination of premium Part A, Part B, or Part B immunosuppressive drug coverage.

Medicare application for people age 65 or older, or turning 65 within 3 months, who want to apply for Part A hospital coverage.

Centers for Medicare & Medicaid Services form used by eligible people with Medicare Part A to request enrollment in Medicare Part B.

Medicare enrollment application for people with End-Stage Renal Disease applying for Part A and Part B coverage.

Centers for Medicare & Medicaid Services form used to document group health plan employment information for certain Medicare special enrollment requests.

Investigational New Drug (IND) Application for human drug testing

Food and Drug Administration clinical trial form used as the statement of investigator for investigational new drug studies.

IND Safety Report - changes, updates and expiration of INDs

Device Master Record used in medical device reporting

Food and Drug Administration MedWatch voluntary reporting form for adverse events, product problems, and product use errors.

Form for submitting investigator curriculum vitae in clinical trials

IRS transmittal form used to submit Forms 1095-B reporting health coverage information.

IRS transmittal form applicable large employers use to submit Forms 1095-C for ACA employer reporting.

Official Centers for Medicare & Medicaid Services CMS 10003-NDMCP for NOTICE OF DENIAL OF MEDICAL COVERAGE/PAYMENT ("INTEGRATED DENIAL NOTICE"), sourced from the CMS forms list and official PDF download catalog for Medicare, Medicaid, provider, plan, coverage, and beneficiary workflows.

Official Centers for Medicare & Medicaid Services CMS 10036 for Inpatient Rehabilitation Facility-Patient Assessment Instrument, sourced from the CMS forms list and official PDF download catalog for Medicare, Medicaid, provider, plan, coverage, and beneficiary workflows.

Official Centers for Medicare & Medicaid Services CMS 10069 for Medicare Waiver Demonstration Application, sourced from the CMS forms list and official PDF download catalog for Medicare, Medicaid, provider, plan, coverage, and beneficiary workflows.

Official Centers for Medicare & Medicaid Services CMS 10114 for NATIONAL PROVIDER IDENTIFIER (NPI) APPLICATION/UPDATE FORM, sourced from the CMS forms list and official PDF download catalog for Medicare, Medicaid, provider, plan, coverage, and beneficiary workflows.

Official Centers for Medicare & Medicaid Services CMS 10125 for DME Information Form - External Infusion Pumps DME 09.03, sourced from the CMS forms list and official PDF download catalog for Medicare, Medicaid, provider, plan, coverage, and beneficiary workflows.