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Forms

Information about where to submit forms and additional resources regarding each area can be found under the Departments, Claims, and Training tabs within the top navigation.

Appeals and Clerical Error Reopening

Find forms for each level of appeal (redetermination and reconsideration requests) as well as state-specific fax cover sheets, a tool to help you determine which form is appropriate for your request, Reopening Request forms, and the Appointment of Representative form (CMS-1696).

Claims

Find forms for submitting claim documentation as well as links to the CMS Beneficiary Notices Initiative (BNI) web page and the CMS Professional paper claim form (CMS-1500) web page.

Electronic Data Interchange (EDI)

Find forms for enrolling in EDI and Electronic Remittance Advice (ERA).

Financial Reporting

Find the Electronic Funds Transfer (EFT) Authorization Agreement (CMS-588) and Helpful Hints for Form CMS-588: Completing Your EFT Application.

Medical Review (MR)

Find Medical Review forms including the Appointment of Representative (CMS-1696), Attestation Statement for signatures forms, and the Request for Waiver of Monthly Face-to Face Visit for Home Dialysis Monthly Capitation Payment (MCP).

Overpayments

Find Overpayment forms including Medicare Secondary Payer (MSP) and Non-MSP specific forms.

Provider Enrollment

Find Provider Enrollment forms including the CMS 855B, 855I, 855R, and 855O enrollment applications, and the CMS Medicare Participating Supplier Agreement (CMS-460).

Training and Education

Find the Training and Education Partnership Request form used to request participation at your event by WPS Medicare Outreach staff.

CMS Forms

All CMS forms can be accessed from the CMS Forms ListExternal Link web page.

Page Last Updated: Wednesday, 26-Nov-2014 12:30:10 CST