Medicare & health appeals forms
CMS claims, appeals and enrollment forms. 47 forms, free to fill online.
All medicare & health appeals forms
- VA 1100 – Agreement to Pay Indebtedness(Veterans Affairs)
- VA 10-1394 – Application for Adaptive Equipment - Motor Vehicle or Other Conveyance(Veterans Affairs)
- VA 10-8678 – Application for Annual Clothing Allowance(Veterans Affairs)
- VA 10-10CG – Application for Comprehensive Assistance for Family Caregivers Program(Veterans Affairs)
- CMS 10798 – Application for Enrollment in Part B Immunosuppressive Drug Coverage(CMS (Medicare))
- VA 10-10EC – Application for Extended Care Services(Veterans Affairs)
- MKT-APP-FAMILY – Application for Health Coverage and Help Paying Costs(HealthCare.gov)
- CMS 18-F-5 – Application for Medicare Part A (Hospital Insurance)(CMS (Medicare))
- CMS-10797 – Application for Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances)(CMS (Medicare))
- CMS 43 – Application for Part A and Part B for People with ESRD(CMS (Medicare))
- CMS 1696 – Appointment of Representative(CMS (Medicare))
- VA 21-4142 – Authorization to Disclose Information to the Department of Veterans Affairs(Veterans Affairs)
- CMS 10106 – Authorization to Disclose Personal Health Information(CMS (Medicare))
- VA 21-0845 – Authorization to Disclose Personal Information to a Third Party(Veterans Affairs)
- VA 10-252 – Authorization to Release Protected Health Information to State/Local Public Health Authorities(Veterans Affairs)
- VA 10-10068A – Camp Lejeune Family Member Program Claim Form(Veterans Affairs)
- VA 10-10068B – Camp Lejeune Family Member Program Treating Physician Report(Veterans Affairs)
- 10-7959A – CHAMPVA Claim Form(Veterans Affairs)
- VA 10-7959D – CHAMPVA Potential Liability Claim(Veterans Affairs)
- CMS 36 – Consent for Home Visit(CMS (Medicare))
- CMS 36P – Consent for Home Visit for PACE Services Evaluation(CMS (Medicare))
- VA 21-2680 – Examination for Housebound Status or Permanent Need for Aid and Attendance(Veterans Affairs)
- VA 10-7959F-2 – Foreign Medical Program (FMP) Claim Cover Sheet(Veterans Affairs)
- VA 21-4142A – General Release for Medical Provider Information to the Department of Veterans Affairs(Veterans Affairs)
- MKT-APPEAL-RECORD – Marketplace Appeal Record Request Form(HealthCare.gov)
- MKT-AUTH-REP – Marketplace Authorized Representative Appointment Form(HealthCare.gov)
- MKT-APPEAL-EAII – Marketplace Eligibility Appeal Request Form (EAII)(HealthCare.gov)
- MKT-APPEAL-FTR – Marketplace Eligibility Appeal Request Form (FTR)(HealthCare.gov)
- VA 21P-8416 – Medical Expense Report(Veterans Affairs)
- CMS-20134 – Medicare Enrollment Application - Medicare Diabetes Prevention Program (MDPP) Suppliers(CMS (Medicare))
- CMS 10287 – Medicare Quality of Care Complaint Form(CMS (Medicare))
- CMS 20033 – Medicare Reconsideration Request Form(CMS (Medicare))
- CMS 20027 – Medicare Redetermination Request Form(CMS (Medicare))
- CMS L564 – Medicare Request for Employment Information(CMS (Medicare))
- CMS 1490S – Patient Request for Medical Payment(CMS (Medicare))
- 10-5345 – Request for and Authorization to Release Health Information(Veterans Affairs)
- CMS 40B – Request for Enrollment in Medicare Part B (Medical Insurance)(CMS (Medicare))
- CMS-4040 – Request for Enrollment in Supplementary Medical Insurance(CMS (Medicare))
- VA 10-10HS – Request for Hardship Determination(Veterans Affairs)
- VA 21-0779 – Request for Nursing Home Information in Connection with Aid and Attendance(Veterans Affairs)
- CMS 1763 – Request for Termination of Medicare Coverage(CMS (Medicare))
- CMS-20031 – Transfer of Appeal Rights(CMS (Medicare))
- VA 10-0137 – VA Advance Directive: Durable Power of Attorney for Health Care and Living Will(Veterans Affairs)
- VA 10-320 – Veteran Reimbursement Claim Form(Veterans Affairs)
- VA 10-323 – Veteran Repayment Plan (RPP) Agreement(Veterans Affairs)
- VA 10-3542 – Veteran/Beneficiary Claim for Reimbursement of Travel Expenses(Veterans Affairs)
- VA 10-0103 – Veterans Application for Assistance in Acquiring Home Improvements and Structural Alterations(Veterans Affairs)