Medicare B Forms and Materials
Some forms are only applicable to certain Cahaba Government Benefit Administrators (GBA) office locations. Use is based on the location in which you submit your Medicare Part B claims.
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/MSP
- Education and Outreach
- Electronic Data Interchange (EDI)
- Enroll/Update Your Records
- Financial
- Policies/Medicare Review
Appeals
- Cahaba GBA Medicare B Redetermination Request Form
- Medicare Redetermination Request Form
- Medicare Reconsideration Request Form
- Request for a Medicare Hearing by an Administrative Law Judge (ALJ)
Claims
- CMS1500 (08-05 Version)
- Medicare Redetermination Request Form (CMS 20027)
- Advance Beneficiary Notice (ABN) (CMS-R-131-G)
- Advance Beneficiary Notice (ABN) (CMS-R-131-L)
Education and Outreach
Electronic Data Interchange (EDI)
- Alabama
- Georgia
- Mississippi
Enroll/Update Your Records
- Affidavit to Opt Out of Medicare
- CMS-855 Enrollment Forms
- CMS-855A Medicare Enrollment Application - Institutional Providers
- CMS-855B - Medicare Enrollment Application - Clinics/Group Practices and Certain Other Suppliers
- CMS-855I - Medicare Enrollment Application - Physicians and Non-Physician Practitioners
- CMS-855R - Medicare Enrollment Application - Reassignment of Medicare Benefits
- Electronic Funds Transfer (EFT) Authorization Agreement
- Participation Agreement
Financial
Policies/Medical Review
Page last updated: Sep. 05, 2008
