Palmetto GBA
Skip
PALMETTO GBA HOME
CONTACT US
E-MAIL UPDATES
Search
Query:
Ohio Part B Carrier Home
What's New
Browse by Specialty
Browse by Topic
CERT
EDI
Learning & Education
Medical Policies
Publications
Resources
Palmetto GBA Home
/
Ohio Part B Carrier
/
Resources
permaLink
Ohio Part B Carrier
Forms
Fill out our
feedback form
to let us know if there is a form not listed that you need.
Forms
Advance Beneficiary Notice
Revised ABN CMS-R-131 Form & Instructions
11/07/2008
Appeals Forms
First Request: Redetermination/Reopening Form
12/11/2009
Telephone Claim Correction Checklist
12/09/2009
Second Level of Appeal: Reconsideration Request Forms
11/07/2008
Electronic Data Interchange (EDI) Forms
EDI Enrollment Forms for OH/WV
11/07/2008
EDI Provider Change Form for Ohio & West Virginia Part B
11/07/2008
Electronic Remittance Advice (ERA) Registration Form
11/07/2008
Fax Cover Sheet: Part B Electronic Claims
11/07/2008
Financial Forms
CMS-588 Electronic Funds Transfer (EFT) Registration Form (Palmetto GBA Version)
09/16/2009
Extended Repayment Plan (ERP) Form
11/07/2008
Financial Statement of Debtor Form: CMS-379
11/07/2008
Overpayment Refund Form
11/07/2008
Medicare Secondary Payer Forms
MSP Explanation Form
08/14/2009
Miscellaneous Forms
Evaluation & Management (E/M) Score Sheets
09/25/2009
Influenza, H1N1 & Pneumococcal Roster Billing Forms
09/22/2009
Medicare Advisory Subscription Form
08/20/2009
Physician Certification Statement for Ambulance Transportation
03/23/2009
Written Inquiry Form: Use to Obtain Confidential Information
03/19/2009
Appointment of Representative Form
11/07/2008
HPSA Opt Out Form
11/07/2008
Meeting Request Form
11/07/2008
Provider Enrollment Forms
Change of Address Form: Provider Groups
01/19/2010
Change of Address Form: Solo Providers or Group Members
01/19/2010
CMS-855 Applications
11/07/2008
Participation Agreement Form and Instructions
11/07/2008
last updated on 01/19/2010