Healthcare Forms

Official Centers for Medicare & Medicaid Services CMS-10455 for Report of a Hospital Death Associated with Restraint or Seclusion, 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-10797 for Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances), 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-R-0235 D1 for DSH Data Use Agreement for Cost Reporting Periods Prior to those that include December 8, 2004, 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-R-0235 D2 for DSH Data Use Agreement for Cost Reporting Periods that Include December 8, 2004 and therafter, sourced from the CMS forms list and official PDF download catalog for Medicare, Medicaid, provider, plan, coverage, and beneficiary workflows.

Official General Services Administration GSA 12002 form for Fire protection, safety, and health programs: high risk use permit form. This federal form supports healthcare workflows and is sourced from the GSA forms library.

Official General Services Administration GSA 19M form for Request for a Medical Exception to the COVID-19 Vaccination Requirement. This federal form supports healthcare workflows and is sourced from the GSA forms library.

Official General Services Administration GSA 3559B form for Follow-up Status Report for Facility Safety, Health or Fire Protection Survey. This federal form supports healthcare workflows and is sourced from the GSA forms library.

Official General Services Administration GSA 3592 form for GSA Employee Report of Unsafe or Unhealthy Working Conditions. This federal form supports healthcare workflows and is sourced from the GSA forms library.

Report of Medical Examination and Vaccination Record

Official HealthCare.gov instructions for the Marketplace paper health coverage application.

Official HealthCare.gov extra person pages for larger household Marketplace paper applications.

Official HealthCare.gov paper application for Marketplace health coverage and financial help.

Official New York State HIPAA authorization form for release of health information.

Official General Services Administration OF 380 form for Reporting and Processing Medical Material Complaints/Quality Improvement Report. This federal form supports healthcare workflows and is sourced from the GSA forms library.

Official General Services Administration OF 517 form for Medical Record - Anesthesia. This federal form supports healthcare workflows and is sourced from the GSA forms library.

Official General Services Administration OF 520 form for Electrocardiographic Record. This federal form supports healthcare workflows and is sourced from the GSA forms library.

Official General Services Administration OF 522 form for Medical Record - Request for Administration of Anesthesia and Performance of Operations and Other Procedures. This federal form supports healthcare workflows and is sourced from the GSA forms library.

Official General Services Administration SF 2809 form for Health Benefits Election Form. This federal form supports healthcare workflows and is sourced from the GSA forms library.

Official General Services Administration SF 2810 form for Notice of Change in Health Benefits Enrollment. This federal form supports healthcare workflows and is sourced from the GSA forms library.

Official General Services Administration SF 2812 form for Report of Withholdings and Contributions for Health Benefits, Life Insurance, and Retirement. This federal form supports healthcare workflows and is sourced from the GSA forms library.

Official General Services Administration SF 2812A form for Report of Withholdings and Contributions for Health Benefits by Enrollment Code. This federal form supports healthcare workflows and is sourced from the GSA forms library.

Official General Services Administration SF 502 form for Medical Record - Narrative Summary (Clinical Resume). This federal form supports healthcare workflows and is sourced from the GSA forms library.

Official General Services Administration SF 503 form for Medical Record - Autopsy Protocol. This federal form supports healthcare workflows and is sourced from the GSA forms library.

Official General Services Administration SF 504 form for Medical Record - History - Part 1. This federal form supports healthcare workflows and is sourced from the GSA forms library.