The forms listed on this page are taken from the Medicare website forms section and are the forms that a chiropractor will need access to.
Enrollment Forms
CMS-10114 This form is used to apply for a National Provider Identifier (NPI)
CMS-855i This form is used to enroll individual doctors in Medicare.
CMS-855b This form is used to enroll a business entity (such as a corporation or partnership) in Medicare.
CMS-855r This form is used by the doctor to reassign his right to be paid to a business entity (such as a corporation or partnership). It is also used by associates to reassign their right to be paid to their employer. Click here to read an alert issued by the OIG regarding the use of this form.
CMS-588 This form is used to set up the Electronic Funds Transfer agreement with Medicare. Click here to read about a special precaution that you must employ with the use of this form.
CMS-460 This form is used to become a Medicare Participating Provider.
CMS-10164A This is the Electronic Data Interchange Registration form.
CMS-10164B This is the Electronic Data Interchange Enrollment form.
Appeals
CMS-20027 This form is used to request a Redetermination, which is the first level of appeal.
CMS-20033 This form is used to request a reconsideration, which is the second level of appeal.
OMHA-100 This form is used to request a hearing before an Administrative Law Judge, which is the third level of appeal.
OMHA-100A This form is used when you are combining multiple claims in one appeal to the Administrative Law Judge.
OMHA-103 This form is used to request an extension of time to file a request for hearing before an Administrative Law Judge.
OMHA-104 This form is used when you wish to waive your right to a hearing before an Administrative Law Judge and just have the records reviewed on the record.
DAB-101 This form is used when you wish to appeal and Administrative Law Judge decision to the Departmental Appeal Board.
CMS-1696 This from is used to appoint a representative (attorney) for an appeal to an Administrative Law Judge.
CMS-20031 This form is used to assign (transfer) the appeal rights from the Medicare beneficiary to the doctor when necessary.
ABN
Advance Beneficiary Notification of Non-Coverage English Version (ABN) This form is used to inform a Medicare patient of their potential financial liability.
Non-Par Advance Beneficiary Notification of Non-Coverage English Version (Non-Par ABN) This form has special language added that is required by Medicare for non participating doctors to inform a Medicare patient of their potential financial liability.
Advance Beneficiary Notification of Non-Coverage Spanish Version (ABN) This form is used to inform a Spanish speaking Medicare patient of their potential financial liability.
ABN Form Instructions The official instructions for completing the ABN
Lab
CMS-116 This form is used to apply for CLIA Waived Certification.