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Your One-Stop Free Source for Medical Billing, Coding, Claims
Reimbursement and Medical Office Management Information
Providing free resources and useful informations for Physicians,
Office Managers, Medical Billers and Medical Coders
ABN (Advance Beneficiary Notice) (downloaded from CMS)

CMS ABN (Advance Beneficiary Notice) Form CMS-R-131 (03/08)
CMS ABN (Advance Beneficiary Notice) for Laboratory Test

New York and New Jersey Part B
Medicare Part B Claim Inquiry/Appeal Request Form

Certificate of Medical Necessity: (downloaded from CMS)

Certificate of Medical Necessity - Pneumatic Compression Devices DME
Certificate of Medical Necessity - Osteogenesis Stimulators
Certificate of Medical Necessity - Transcutaneous Electrical Nerve Stimulator (TENS) -
DME
Certificate of Medical Necessity - Seat Lift Mechanisms - DME
Certificate of Medical Necessity - DME

Request for Certification in the Medicare and/or Medicaid Program to Provide
Outpatient Physical Therapy and/or Speech Pathology Services

NATIONAL PROVIDER IDENTIFIER (NPI) APPLICATION/UPDATE FORM (downloaded from CMS)


Medicare Provider Enrollment Forms:

Medicare Enrollment Application - Physicians and Non-Physician Practitioners (Individual)
(downloaded from CMS)   CMS 855i (02/08) (EF 07/09)

Medicare Enrollment Application - Clinics/group Practices and Certain other Suppliers
CMS 855B (02/08) (EF 07/09)

Medicare Enrollment Application - Reassignment of Medicare Benefits (downloaded from CMS)
CMS 855R (02/08)

Electronic Funds Transfer (EFT) Authorization Agreement (downloaded from CMS) CMS 588

****Form CMS588 is NOW mandatory. Medicare now is eliminating the issuance of paper
checks to the providers.

Workers Compensation Common Forms

State of New York:
New York State Attending Doctor's Report and Carrier/Employer Billing Form
**Continuation to Carrier/Employer Billing Portion
New York State WC Employee's Claim for Compensation
Medical Proof of Change in Condition in Support of Application for Reopening
Practitioner's Report of Functional Capacity Evaluation - for Physical or Occupational
Therapist

State of TEXAS:
Private Providers of Vocational Rehabilitation Services (Rev. 11/06)
Explanation of Benefits (Rev. 07/07)
Medical Fee Dispute Resolution Request (Rev. 02/07) (provider who are disputing reimbursement!)
Workers Compensation Work Status Report

State of New Jersey:
A Workers' Guide to Workers' Compensation in New Jersey (complete brochure)
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