Financial/Audit & Reimbursement Forms
- Accelerated/Advance Payment Request Form

- Checklist for Home Health and Hospice Cost Report Submission
- Checklist for Home Office Cost Statement Submission
- Credit Balance Report

- Documentation Supporting a Request for Extended Repayment Plan
- Duplicate Remittance Advice Request Form

- Home Health Agency Cost Report Form (Form CMS-1728-94)

- Hospice Cap Form – "Provider Self-Determined Aggregate Cap Limitation"

- Hospice Cap Form – for Prorated Cap Amount

- Hospice Cost Report Form (Form CMS-1984-99_)

- Hospice Cost Report Form (Form CMS-1984-14)
– NOTE: For cost reporting periods beginning on or after October 1, 2014 - Immediate Offset Request Form
Submit an offset request instantly through myCGS! Click here to learn more.
- Overpayment Refund Form

- Stop Payment Affidavit

Updated: 10.24.16

