Home health certifications, beneficiary notices, assessment instruments, Part D coverage requests and MAC prior authorization forms, with who completes each one.
Medicare forms come from CMS and from the Medicare Administrative Contractors (MACs) that review claims. The ones clinicians meet most are the Home Health Certification and Plan of Care (CMS-485), the Advance Beneficiary Notice of Non-coverage (CMS-R-131), the CMS model Request for Medicare Drug Coverage Determination for Part D, and the Physician Certification Statement for non-emergency ambulance transport. This hub lists 34 forms, from certifications and beneficiary notices to CGS prior authorization requests for hospital outpatient and ambulatory surgical center services.
Few are filled in by the physician alone. The home health agency drafts the CMS-485, and the certifying physician, NP, CNS or PA reviews, signs and dates it. Notices such as the ABN (CMS-R-131) and MOON (CMS-10611) are completed by the provider and signed by the patient; 2 forms here have a Spanish version. MDS 3.0, OASIS-E2 and the other assessment instruments go electronically to CMS iQIES. Vero Documents fills PDF forms from the visit note and the chart, and the clinician reviews and signs.
Certifies a Medicare patient's homebound status and need for skilled home health care and sets out the plan of care (orders, diagnoses, goals) for the certification period.
Aviso anticipado de no cobertura para el beneficiario (ABN)
Warns an Original Medicare patient before a service that Medicare may not pay, so the patient can choose to receive it and accept financial liability.
Certifies that a Medicare patient's non-emergency ambulance transport (scheduled, repetitive or unscheduled) is medically necessary because other transport is contraindicated.
Certifies that a patient with diabetes has a qualifying foot condition and is under a comprehensive diabetes plan of care, so Medicare covers depth or custom-molded shoes and inserts.
Standard clinical assessment of every resident of a Medicare/Medicaid-certified nursing home or swing bed, used for care planning, SNF PPS (PDPM) payment and quality measures.
Standard comprehensive assessment of Medicare/Medicaid home health patients at start of care, resumption, follow-up, transfer and discharge, used for payment (PDGM case mix) and quality reporting.
Lets the author of a medical record entry or order attest to a missing or illegible signature so the record can be used in Medicare medical review.
CMS-2728Documents that a patient has reached end-stage renal disease requiring regular dialysis or a transplant, to establish ESRD Medicare entitlement and register the patient with the ESRD program.
Admission and discharge assessment of Medicare patients in inpatient rehabilitation facilities, used for IRF PPS case-mix payment and the IRF Quality Reporting Program.
Informs a Medicare patient receiving more than 24 hours of observation services that they are an outpatient, not an inpatient, and what that means for cost sharing and SNF coverage.
Standard hospice patient assessment at admission, HOPE update visits and discharge, used for the Hospice Quality Reporting Program.
Documents why an admission to a non-participating hospital was a Medicare emergency so that the inpatient or outpatient emergency services can be paid.
CMS-2746Reports the death of a dialysis or kidney transplant patient, with causes of death and treatment status, to the ESRD Medical Information System.
Standard admission, planned/unplanned discharge and expired assessment of patients in long-term care hospitals for the LTCH Quality Reporting Program.
Asks a Medicare Part D plan to cover a drug (prior authorization, formulary, step-therapy, quantity-limit or tiering exception), with a prescriber supporting statement.
Cover sheet for a DMEPOS prior authorization request (power mobility devices, pressure-reducing support surfaces, lower limb prostheses, orthoses, pneumatic compression devices, manual wheelchairs).
Appeals a Part D plan's denial of drug coverage or payment (first-level appeal), with the prescriber's explanation of medical need.
Requests Medicare prior authorization for blepharoplasty and related eyelid procedures in a hospital outpatient department, with answers to the coverage questions.
Requests Medicare prior authorization for botulinum toxin injections in a hospital outpatient department, with answers to the coverage questions.
Requests Medicare prior authorization for vein ablation in a hospital outpatient department, with answers to the coverage questions.
PAR 457Requests prior authorization under the CMS WISeR Model for selected services (e.g., skin and tissue substitutes, electrical nerve stimulator implantation, knee arthroscopy for osteoarthritis) for Ohio Original Medicare patients.
Requests Medicare prior authorization for facet joint injections, medial branch blocks and radiofrequency ablation in a hospital outpatient department, with answers to the coverage questions.
Lets the treating physician ask the DME MAC for a copy of the prior authorization decision letter for a DMEPOS item ordered for a patient.
Asks the Part D Independent Review Entity to review a plan's adverse redetermination on drug coverage (second-level appeal).
Requests Medicare prior authorization for rhinoplasty in a hospital outpatient department, with answers to the coverage questions.
Requests Medicare prior authorization for panniculectomy in a hospital outpatient department, with answers to the coverage questions.
Requests Medicare prior authorization for implanted spinal neurostimulators in a hospital outpatient department, with answers to the coverage questions.
Requests Medicare prior authorization for cervical fusion with disc removal in a hospital outpatient department, with answers to the coverage questions.
Requests Medicare prior authorization for up to 40 round trips in a 60-day period of repetitive, scheduled non-emergent ambulance transport (e.g., dialysis, wound care).
Requests Medicare prior authorization for blepharoplasty performed in an ambulatory surgical center (Ohio).
Requests Medicare prior authorization for vein ablation performed in an ambulatory surgical center (Ohio).
Requests Medicare prior authorization for rhinoplasty performed in an ambulatory surgical center (Ohio).
Requests Medicare prior authorization for panniculectomy performed in an ambulatory surgical center (Ohio).
Requests Medicare prior authorization for botulinum toxin injections performed in an ambulatory surgical center (Ohio).
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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The certifying physician or an allowed practitioner: a nurse practitioner, clinical nurse specialist or physician assistant. The home health agency usually drafts the form. The clinician approves the orders in items 10 to 22 and signs and dates the certification in item 27. The signed copy goes back to the agency, which keeps it and sends it to the MAC or reviewers on request. Medicare accepts any plan-of-care format that has the required elements.
Yes. CMS publishes the Advance Beneficiary Notice in English and Spanish (Formulario CMS-R-131-S), including large-print versions, in one ZIP download with Word, PDF and fillable PDF files. The notifier completes sections A to F. The patient chooses an option in section G, then signs and dates it. Give it to the patient before the service, keep the signed copy in the record, and add the GA or GZ modifier to the claim.
Pages 3 and 4 of the CMS model Request for Medicare Drug Coverage Determination: the supporting information for an exception request or prior authorization. The enrollee, a representative or the prescriber can file it. Plans must accept the model form and may use their own branded version. Fax or mail it to the patient's Part D plan. If the prescriber certifies urgency, the plan makes an expedited decision within 24 hours.
For repetitive scheduled transports, the attending physician. For unscheduled transports, a PA, NP, CNS, RN or discharge planner may sign. CMS publishes no standard PCS form, so each ambulance supplier provides its own. The supplier keeps the signed statement on file and sends it with prior authorization requests or when the MAC asks. A PCS for repetitive transport must be dated no earlier than 60 days before the service.