| Title |
Last Updated |
| Medicare Participating Physician Or Supplier Agreement |
August 23, 2019 |
| Request For Validation Of Accrediation Survey For Home Health Agency |
May 6, 2019 |
| Medicare Enrollment Application Physicians And Non-Physician Practitioners |
March 12, 2019 |
| Certificate Of Medical Necessity |
March 12, 2019 |
| Rehabilitation Hospital Work Sheet |
February 4, 2019 |
| Rehab Unit Criteria Worksheet |
February 4, 2019 |
| Patients Request For Medical Payment |
February 4, 2019 |
| Laboratory Personnel Report (CLIA) |
November 6, 2018 |
| Appointment Of Representative |
November 6, 2018 |
| National Provider Identifier (NPI) Application-Update Form |
September 25, 2018 |
| Fire Smoke Zone Evaluation Worksheet For Health Care Facilites |
September 13, 2018 |
| Fire Safety Survey Report Abulatory Surgical Centers Medicare |
September 13, 2018 |
| Request For Retirement Benefit Information |
June 12, 2018 |
| Long Term Care Facility Application For Medicare And Medicaid |
June 8, 2018 |
| Cetificate Of Medical Necessity Osteogenesis Stimulators |
June 8, 2018 |
| Certificate Of Medical Necessity Transcutaneous Electrical Nerve Stimulator (TENS) |
June 8, 2018 |
| Certificate Of Medical Necessity Seat Lift Mechanisms |
June 8, 2018 |
| Certificate Of Medical Necessity Pneumatic Compression Devices |
June 8, 2018 |
| Certificate Of Medical Necessity Continuation Form |
June 8, 2018 |
| Roster-Sample Matrix |
June 8, 2018 |
| Clinical Laboratory Improvement Amendments (CLIA) Application For Certification |
June 8, 2018 |
| Model Letter Requesting Identification Of Extension Units |
June 8, 2018 |
| Medicare Enrollment Application-For Eligible Ordering And Referring Physicians And Non-Physician Practitioners |
May 16, 2017 |
| Medicare Enrollment Application Reassignment Of Medicare Benefits |
March 17, 2017 |
| Medicare Enrollment Application Institutional Providers |
March 17, 2017 |
| Medicare Enrollment Application Clinics-Group Practices And Certain Other Suppliers |
March 17, 2017 |
| Medicare Enrollment Application Durable Medical Equipment Prosthetics Orthotics And Supplies (DMEPOS) Supplier |
November 30, 2016 |
| Kitchen-Food Service Observation |
July 6, 2016 |
| Hospice Request For Certification In The Medicare Program |
March 30, 2016 |
| Medicare Quality Of Care Complaint Form |
March 30, 2016 |
| 1-800-Medicare Authorization To Disclosure Personal Health Information |
July 16, 2015 |
| Certificate Of Data Destruction For Data Acquired |
June 29, 2015 |
| Medicaid Agency Data Use Agreement |
June 29, 2015 |
| Request For Medicare Hearing By An Administrative Law Judge |
June 8, 2015 |
| Notice Of Denial Of Medical Coverage |
April 13, 2015 |
| Responsibilites Of Medicare Participating Hospitals In Emergency Cases Investigation |
April 13, 2015 |
| Electronic Funds Transfer (EFT) Authorization Agreement |
April 13, 2015 |
| Addendum To Data Use Agreement (DUA) |
April 13, 2015 |
| Advance Beneficiary Notice (ABN) |
April 13, 2015 |
| Outpatient Physical Therapy-Speech Pathology Survey Report |
April 13, 2015 |
| Freedom Of Information ACT Request |
April 13, 2015 |
| Intermediate Care Facilities For Individuals With Intellectual Disabilities Survey Report |
April 8, 2014 |
| Intermediate Care Facilities For Individuals With Intellectual Disabilities Deficiencies Report |
April 8, 2014 |
| Individual Observation Worksheet |
April 8, 2014 |
| Application For Access To CMS Computer System |
January 7, 2014 |
| Section 1011 Provider Enrollment Application |
December 3, 2013 |
| Section 1011 Dispute Resolution Request |
September 17, 2013 |
| Fire Safety Survey-2000 Life Safety Code Worksheet For Rating Residents |
June 14, 2013 |
| Fire Safety Survey Report-2000 Life Safety Code Intermediate Care Facilities For The Mentally Retarded Small |
June 14, 2013 |
| Fire Safety Survey Report-2000 Life Safety Code Intermediate Care Facilities For The Mentally Retarded Large |
June 14, 2013 |
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