Part A Forms
Forms are available in PDF format. If you don't have Adobe Reader software, you can download
it at no cost.
Instructions: Type your information in the form fields. Then, save, print and sign (if required). Illegible handwritten forms may reject or delay processing.
TIP: Click on an arrow or heading to access more content under each topic.
Appeals
- Redetermination Request
(or myCGS) - Multiple Beneficiary/Single Appeal Request

- myCGS Reconsideration Request (2nd Level Appeal)
See Appeals/Redeterminations for additional information.
Beneficiary 2nd Level Screening/BIU
Beneficiary Notices of Noncoverage
Claims
- Claim Overlap Dispute Request

- Clerical Error Reopening Adjustment Request

- LTCH Site Neutral Adjustment Request

See Claims for additional information.
CMS Forms
Customer Service
EDI
Enrollment
- Medicare Enrollment Application (CMS-855A)

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

See Provider Enrollment for additional information.
Medical Policy
Medical Review
See Medical Review for additional information.
Overpayment & Refunds
Prior Authorization
Updated: 06.09.2026

