Medicare Forms

Notifies Original Medicare beneficiary before receiving a service that Medicare may not pay for. Patient decides whether to proceed and accept financial responsibility.

Request for Administrative Law Judge hearing or review of dismissal. Third-level appeal for Medicare claim denials when amount in controversy meets threshold.

Enrollment form for Dual-Eligible Special Needs Plans (D-SNPs) for individuals with both Medicare and Medicaid coverage.

Provides detailed explanation of why Medicare will no longer cover services. Issued alongside the NOMNC when beneficiary requests an expedited review.

Explains why hospital services are ending and the patient's right to appeal. Issued when a patient requests an expedited review of discharge.

Application for Extra Help with Medicare prescription drug plan costs. Can save up to $5,000/year on Part D premiums, deductibles, and copays.

Notification given within 2 days of hospital admission informing patients of their discharge rights and the appeal process.

Authorizes another person to file grievances, request coverage determinations, or appeal on behalf of a Medicare Advantage or Part D enrollee.

Request to disenroll from a Medicare Advantage or Part D plan and return to Original Medicare. Available during applicable enrollment periods.

Model enrollment form for Medicare Advantage or Part D prescription drug plans. Plans customize the CMS template but must include all required elements.

Request for Medicare Appeals Council review. Fourth-level appeal after an Administrative Law Judge decision.

Must be given to patients in outpatient observation status for more than 24 hours, explaining they are not admitted as inpatients and the financial implications.

Application for enrollment in Medicare Part B (medical insurance). Used during Initial Enrollment, General Enrollment, or Special Enrollment Periods.

Enrollment in a Medicare Part D prescription drug plan. Current medication list is the critical input for plan comparison and selection.

First-level appeal for Original Medicare (Part A/B) claim denials. Must be filed within 120 days of the initial determination.

Application for QMB, SLMB, or QI programs that help pay Medicare premiums, deductibles, and copays. Over 6 million eligible but unenrolled.

Application for Medicare Supplement insurance. During the 6-month Open Enrollment Period (starting at age 65 with Part B), insurers cannot deny coverage or charge more for pre-existing conditions.

Application exercising guaranteed issue rights when leaving an MA plan, losing employer coverage, or plan discontinuation. 63-day window applies.

Used to submit Medicare Secondary Payer information to the MAC when another insurer is primary to Medicare.

Screening worksheet used at every admission or outpatient encounter to determine whether Medicare is primary or secondary payer.

Notifies beneficiary that covered services (SNF, home health, CORF, hospice) are ending, with right to expedited review by a Quality Improvement Organization.

Application for Medicare Part A and Part B during a Special Enrollment Period for exceptional conditions such as natural disasters or employer misinformation.

Application for Part B immunosuppressive drug coverage for individuals who lose Part B but need ongoing immunosuppressive drug coverage after a kidney transplant.

Request for Part D coverage determination including formulary exception, tiering exception, or waiver of utilization management such as step therapy or quantity limits.

Level 2 appeal sent to the Independent Review Entity after plan upholds denial. Must be filed within 60 days of the redetermination decision.

Level 1 appeal of a Part D coverage determination denial. Plan must decide within 7 days (standard) or 72 hours (expedited).

Employer verification of group health plan coverage dates. Required alongside CMS-40B when using a Special Enrollment Period after employer coverage ends.