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You can view, print, or electronically submit forms online by accessing the links below.
Simply click on the applicable link and you will be directed accordingly.
Please call 1-800-MEDICARE (1-800-633-4227) for assistance filling out these forms. TTY users should call 1-877-486-2048.
You will need Adobe Acrobat Reader software to view the PDF versions.
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Title
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Form Number
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Purpose
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Language Availability
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Medicare Authorization to Disclose Personal Health Information NEW! Online Submission
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CMS-10106
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Authorizes CMS to disclose personal health information to persons or organizations that you designate.
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English
Spanish
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Patient's Request for Medical Payment |
CMS-1490S
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Used by the beneficiary to file a claim with Medicare for services and/or supplies received.
Click on the link on the left to access the forms and instructions. You will need to print out both the CMS 1490S form and the applicable instructions. The address for form submission is included in the instructions.
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English
Spanish
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Medicare Appeals Form |
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Used by the beneficiary to appoint a representative, transfer appeal rights, request a hearing, request a redetermination, or request a reconsideration; depending on the situation.
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English
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A list of all CMS forms can be found at http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp
Page Last Updated: October 7, 2009
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