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Compliance Enforcement Deadline
03/31/2012 11:59pm

2012-03-31 23:59:00 GMT-05:00
HHS
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Jurisdiction 11 Part B
Forms

Here are the Palmetto GBA forms, which can be selected by category. Fill out our feedback form to let us know if there is a form not listed that you need.

 


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Influenza and Pneumococcal Roster Billing Forms12/01/2011
J11 Part B Redetermination Requests10/25/2011
Advance Beneficiary Notice Form and Instructions (CMS-R-131)Open in New Window07/18/2011
Appointment of Representative Form07/18/2011
Change of Address Form: Provider GroupsOpen in New Window07/18/2011
Change of Address Form: Solo Providers or Group MembersOpen in New Window07/18/2011
CMS-588 Electronic Funds Transfer (EFT) Registration Form07/18/2011
CMS-855 ApplicationsOpen in New Window07/18/2011
Financial Statement of Debtor Form: CMS-37907/18/2011
MSP Explanation Form07/18/2011
Overpayment Refund Form07/18/2011
Written Inquiry Form: Use to Obtain Confidential Information07/18/2011
Palmetto GBA 1099 B Notice Request Form07/11/2011
Provider Outreach and Education Request Form06/28/2011
Electronic Claims and Fax Attachments06/14/2011
Medicare Opt-Out Affidavit03/01/2011
Participation Agreement Form and Instructions03/01/2011
Provider Medicare Voluntary Refunds: Cannot Be Handled Via 'Immediate Offset'03/01/2011
Second Level of Appeal: Reconsideration Request Forms03/01/2011

 

last updated on 2/01/2012
ver 1.1.1