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 (22K)
- CSI/ELGB USER ID Access Request Form (32K)
- Electronic Funds Transfer (EFT) Authorization Agreement (21K)
- Medicare Secondary Payer (MSP) Questionnaire (43K)
- Offset Request Form (42K) - Updated 01.15.08
- Redeterminations Request Form (16K)
- Reopening Request Form (50K) - Updated 01.15.08
- Suggested Intake Form (27K)
- Voluntary Overpayment Refund (12K)
- Publication Order Form (23K)
