Medicare Fiscal Intermediary Forms
Most forms are in the Portable Document File (PDF) format. If you are unable to read these documents, you may not have the most current version of Adobe Reader. To download a free, current copy of Adobe Reader, click the Adobe icon below.
Forms are organized by these topics:
- Appeals
- Claims
- EDI
- Education and Outreach
- Enroll/Update Your Records
- Financial
- Policies/Medical Review
Appeals
- Cahaba Medicare A Redetermination Request Form
- CMS Medicare Redetermination Request Form
- CMS Medicare Reconsideration Request Form
- Request for a Medicare Hearing by an Administrative Law Judge (ALJ)
Claims
EDI
- EDI Services Enrollment Application
- EDI Services Enrollment Update Application
- EDI Services System Access Request
- EDI Services System Access Update Request
- EDI Services Vendor Application
- Network Service Agreement
Education and Outreach
- Cahaba’s E-mail Notification Service Subscription Form
- Education Materials Order Form
- Medicare A Newsline Forum Form
- Medicare A Newsline Paper Copy Request Form
Enroll/Update Your Records
- Cahaba Provider-Based Attestation Statement
- CMS-855A Provider Enrollment Checklist
- Notification of Special Documentation
- Off Campus Medicare Outpatient Coinsurance Notice
Financial
- Check Reimbursement Form
- Credit Balance Reporting (CMS-838)
- Electronic Funds Transfer (CMS-588)
- Listing of Medicare Bad Debts and Appropriate Supporting Data
- Overpayment Refund Form
Policies/Medical Review
Page last updated: May 12, 2008