Part B Forms

Home Provider Part B Self-Service Forms

Appeals

Redetermination Request Form (CMS 20027) external pdf

Reopening Request Form 45KB adobe portable format document
Revised 02/01/07 to add a field in Section A asking for the Requester's Relationship to Provider/Beneficiary.

Reconsideration Request Form (CMS 20033) external pdf

Fact Sheet: Which Form Should I Use? adobe portable format document

WPS Medicare Part B Redetermination Request Form adobe portable format document


Claims

ABN Forms link to website outside of wpsmedicare


CMS Forms link to website outside of wpsmedicare


EDI

Electronic Funds Transfer Form adobe portable format document

Electronic Data Interchange (EDI) Forms link to website outside of wpsmedicare


Enrollment

Electronic CMS 855 Forms Available

CMS 855 Medicare Enrollment Applications link to website outside of wpsmedicare

CMS 460 Medicare Participating Physician or Supplier Agreement adobe portable format document

CMS 588 Electronic Funds Transfer (EFT) Authorization Agreement adobe portable format document

Electronic Data Interchange (EDI) Enrollment Form adobe portable format document

Enrollment Forms link to website outside of wpsmedicare


Financial

Overpayment Notification Form and Instructions (05/11/09)

Voluntary Refund Form adobe portable format - This form is only to be used when accompanied by a check.

Immediate Offset Request Form adobe portable format document


Other Forms

Freedom of Information Act Authorization Form adobe portable format

Medicare Participating Physician or Supplier Agreement adobe portable format


Page Last Updated: Friday, 06-Nov-2009 14:16:21 CST