The Senior Living Guide - Medicare Online Forms

Medicare Online Forms

Medicare Online Forms

Medicare Authorization to Disclose Personal Health Information:

Form CMS-10106 Authorizes CMS to disclose personal health information to persons or organizations that you designate. If this is for a deceased beneficiary, please include a copy of the legal documentation which indicates your authority to make a request for information. (For example: Executor/Executrix papers, next of kin attested by court documents with a court stamp and a judge's signature, a Letter of Testamentary or Administration with a court stamp and judge's signature, or personal representative papers with a court stamp and judge's signature.) Also, please explain your relationship to the beneficiary..

Patient’s Request for Medical Payment:

Form CMS-1490S Used by the beneficiary to file a claim with Medicare for services and/or supplies received.

Medicare Appeal Forms:

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.

CMS-1696 Appointment of Representative.

You should use this form if you want to name someone to represent you to help appeal your claim.

CMS-20031 Transfer of Appeal Rights.

Use this form to transfer your appeal rights to your provider or supplier. Your provider or supplier may not have the right to appeal your claim in some situations.

CMS-20027 Medicare Redetermination Request Form.

If you don't agree with the initial claim decision by Medicare, you should use this form to appeal your claim. This is called a redetermination and is the first level of the appeals process. This is done by the Medicare Contractor who processed your claim. Any dollar amount can be appealed at this level, but it needs to be submitted within 120 days from the date you received the initial claim decision. This is normally the date shown on your Medicare Summary Notice (MSN). To file an appeal, you can also follow the instructions on your MSN by signing and returning the notice to the Medicare Contractor who processed your claim.

CMS-20033 Medicare Reconsideration Request Form.

Use this form if you are dissatisfied with the redetermination decision made during your first level of appeal. This form is used for the second level of appeals for your claim. This request is called a reconsideration and is done by a Qualified Independent Contractor (QIC). Any dollar amount can be appealed at this level, but it needs to be submitted within 180 days from the date of your redetermination decision.

CMS-20034A/B Request for Medicare Hearing by an Administrative Law Judge.

Use this form is you are dissatisfied with the QIC reconsideration decision made during your second level of appeal. This form is used to request a hearing by an Administrative Law Judge (ALJ). This is the third level of appeals. This request needs to be submitted within 60 days from the date of your reconsideration decision. The claim(s) you are appealing must be more than $120.

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