This page contains downloadable copies of paper forms.  Download them to your PC, print them on your printer, and follow instructions as indicated on each form.

An "*" notes a form that is contained on an outside website.

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(*) CMS-379 - Financial Statement of Debtor

This form is used by a Provider that is a Sole Proprietor to request and Extended Repayment Plan for an overpayment debt.

  CMS-379 - Financial Statement of Debtor (374k) 

(*) CMS-460 - Medicare Participating Physician Or Supplier Agreement

  CMS-460 - Medicare Participating Physician or Supplier Agreement (59k)

 (*) CMS-588 - Authorization Agreement for Electronic Funds Transfer (EFT)

This form is used to have your Medicare payments deposited directly into your bank account. It eliminates paperwork and saves time by reducing routine banking.

  CMS-588 - Authorization Agreement for Electronic Funds Transfer (EFT) (59k)

 (*) CMS-855 - Provider Enrollment Forms

This form must be completed by all providers of services and suppliers of medical and other health services for enrollment in the Medicare program. This form can be printed and submitted to Highmark Medicare Services, but it must be signed with an original signature and sent via U.S. Mail to:

Provider Enrollment Services
P.O. Box 890157
Camp Hill, PA 17089-0157

For instructions on completing these forms, please see Chapter 3 of our Part B Reference Manual.

  CMS-855B - Clinics/Group Practices and Certain Other Suppliers (1,457k)
  CMS-855I - Physicians and Non-Physician Practitioners (780k)
  CMS-855R - Reassignment of Medicare Benefits (308k)

CMS-1500 - Health Insurance Claim Form (Sample)

All paper claims you submit on behalf of your Medicare patients must be submitted using the HCFA-1500 claim form. The only exception is ambulance claims which should continue to be submitted on the HCFA 1491 claim form. The HCFA-1500 claim form is furnished to you printed in red ink. This is the only format that is accepted. Photocopies or Xerox copies of the form will not be processed. See Chapter Nine of our Part B Reference Manual for more information on obtaining this form.

  CMS-1500 - Health Insurance Claim Form (Sample) (20k) 

(*) CMS-1696 - Appointment of Representative

This form must be completed by a Medicare beneficiary/provider or supplier if he/she chooses to have an Appointed Representative. The assigned person will act as the representative of the beneficiary/provider/supplier for an appeal of a claim(s). The beneficiary/provider/supplier is authorizing their representative to make or give any request or notice; to present or to elicit evidence; to obtain information; and to receive any notice in connection with the claim or claims in question.

  CMS-1696 - Appointment of Representative (188k) 

(*) CMS-R-131 ABN Forms

There are two CMS-R-131 forms, the General Use form ("ABN-G") and the Laboratory Tests form ("ABN-L"). Both CMS-R-131 ABN forms are standard forms which may not be modified. An ABN is a written notice that a physician or supplier gives to a medicare beneficiary before items or services are furnished when the physician or supplier believes that Medicare probably or certainly will not pay for some or all of the items or services.

  CMS-R-131-G (General Use)
  CMS-R-131-L (Laboratory Tests) English 

HCFA-1450 (UB-92)

The HCFA-1450 (UB-92) form is used by institutional and other selected providers to complete a Medicare Part A paper claim for submission to Medicare Fiscal Intermediaries.

If you intend to make paper copies of the Form HCFA-1450 (in PDF) for claims submission purposes, please contact the specific health care payer that you intend to submit these claims to before submitting these claims for payment. Some payers may be able to accept a black & white copy of Form HCFA-1450. Other payers may not accept a black & white copy if they are utilizing Optical Character Recognition (OCR) equipment.

  HCFA-1450 (UB-92) (17k)   (Note: This PDF is not 100% to scale.) 

HCFA-1490S

HCFA-1490S (Patient's Request for Medicare Payment) is used by Medicare beneficiaries for submitting Medicare covered services. If a beneficiary wishes to submit a claim, he or she must do so on the HCFA-1490S form. A beneficiary must also attach to the HCFA-1490S form any bill (s) he or she receives from providers/suppliers.

  HCFA-1490S (13k) 

HCFA-1491

HCFA-1491 (Request for Medicare Payment – Ambulance) is used to submit Medicare Part B covered ambulance services. Medicare Part B covered ambulance services can also be submitted using the HCFA-1500 claim form. The HCFA-1491 claim form is furnished to you printed on blue paper and black ink. This is the only format that is accepted. Photocopies or Xerox copies of the form will not be processed. See Chapter Nine in our Part B Reference Manual or the Ambulance Billing Guide for more information on obtaining this form.

  HCFA-1491 (21k) 

4579E - Medicare Redetermination Request Form

Please print form, complete all claim review information, and mail to the address that appears on top of the form.

  4579E - Medicare Redetermination Request Form (16k) 

8322 - Return Of Monies To Medicare - Part B

Providers should send us this updated form to faciliate prompt and accurate credit of unsolicited monies or voluntary refunds to Medicare. Plese complete the form in its entirety.

  8322 - Return of Monies To Medicare - Part B (23k)

8322-1A - Return Of Monies To Medicare - Part A

Providers should send us this updated form to faciliate prompt and accurate credit of unsolicited monies or voluntary refunds to Medicare. Plese complete the form in its entirety.

  8322-1A - Return of Monies To Medicare - Part A (25k)

8985 - E&M Score Sheet

Sheets used to "score" provider's evaluation and managment services.

  8985 - E&M Score Sheet (79k) 

10279A - PMNC Form

A Physician's Medical Necessity Certification (PMNC) Form is now required for all non-emergency scheduled and unscheduled transports.

  10279A - PMNC Form (27k)

Extended Repayment Plan (ERP) Form

This form is used by the provider to request and Extended Repayment Plan for an overpayment debt. The form contains a checklist, certification statement and model formats for providing required ERP information to Highmark Medicare Services.

  Extended Repayment Plan (ERP) Form (179k) 

Highmark Medicare Services Cover Sheet for Submitting Medical Documentation for Electronic Claims

When a paper attachment is required to adjudicate an electronic claim, EDI billers should complete this form. The completed form and attachment must be mailed together at least seven days prior to submitting an electronic claim that contains an attachment.

  Highmark Medicare Services Cover Sheet for Submitting Medical Documentation for Electronic Claims (39k)

Highmark Medicare Services Freedom of Information Act (FOIA) Document Request Form

The form may be utilitzed to complete a FOIA request. Please print the form, complete all information, and mail/fax to the address that appears at the bottom of the form.

  Highmark Medicare Services Freedom of Information Act (FOIA) Document Request Form (71k)

HIPAA Compliant Authorization For The Release of Patient Information Pursuant To 45 CFR 164.508

The form may be utilized to complete a valid HIPAA compliant authorization when requesting records for someone other than yourself. The authorization contains the core elements and required statements necessary to be honored under the Freedom of Information Act (FOIA). Please print the form, complete all information, and mail/fax with your FOIA request.

  HIPAA Compliant Authorization For The Release of Patient Information Pursuant To 45 CFR 164.508 (70k)

HMO Copayment Receipt Form

This form is used by providers to request secondary payment when the primary payor is an employer-sponsored health maintenance organization (HMO).

  HMO Copayment Receipt Form (9k) 

Request for Part B Reconsideration by a Qualified Independent Contractor (QIC)

Effective for Redetermination Notices dated on or after January 1, 2006, if you wish to request a second level appeal, it must be submitted to a QIC. This form should be used for QIC requests.

  Request for Part B Reconsideration by a Qualified Independent Contractor (QIC) (11k)