Part A Resources: Forms
- IDE Request Requirements – 08/03/12
- Interactive Remittance Advice Form – 07/12/12
- Interactive UB-04 Form – 04/16/12
- Immediate Offset Request Form – 03/30/12
- Duplicate Remittance Advice Request Form – 09/29/2011
- First Request: Redetermination Form – 09/29/2011
- Part A Ask-the-Contractor Teleconference (ACT) Request for Inquiry Items Form – 09/29/2011
- Request for Quality Improvement Organization (QIO) Prepayment Review Forms – 09/29/2011
- Clerical Error Reopening Request Form – 09/28/2011
- Provider Outreach and Education Request Form – 09/28/2011
- CMS-588 Electronic Funds Transfer (EFT) Registration Form – 09/26/2011
- Credit Balance Certification Form – 09/26/2011
