DME MAC Jurisdiction C Forms
Welcome to the DME MAC Jurisdiction C forms section. As forms are identified and updated for Jurisdiction C, we will post them to this section. For easy reference, you may either bookmark this location or, add them to your "MyCGS" customizable Web site.
The forms offered below are in Adobe PDF format. Download
a free copy of Acrobat Reader. 
- ADMC Request (114K)
- Suggested Intake Form (27K)
- Medicare Secondary Payer (MSP) Questionnaire (43K)
- Offset Request Form (42K) - Updated 06.12.08
- Voluntary Overpayment Refund (105K) - Updated 09.04.08
- Reopening Request Form (327K) - Updated 08.05.08
- Redetermination Request Form (141K)
- CSI/ELGB USER ID Access Request Form (67K) - Updated 09.23.08
- Electronic Funds Transfer (EFT) Authorization Agreement (21K)
- Publication Order Form (23K)
- Physician Documentation Request Letter (37K)
- Intermittent
Urinary Catheterization (32K)
