Part
B Forms
Welcome to the Part B forms section. As forms are identified and updated for Part B, 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. 
Electronic Data Interchange Forms
Effective July 1, 2006, all forms must be sent to the EDI Department in North Carolina for processing. This includes forms for new setups as well as forms for changes to existing setups. Failure to send these forms to the North Carolina office will result in the application being retuned to you.
New EDI billers are required to complete the EDI Enrollment Form and the Part B EDI Customer Profile.
New Medicare Claims Express (MCE) users are required to complete the Part B EDI Enrollment form, Part B EDI Customer Profile, and Part B MCE User Agreement.
Existing EDI billers may change or add information to their profile using the Part B EDI Customer Profile only.
- ANSI 4010A1 276/277 Companion Document
- Network Service Vendor Agreement
- Part B Companion Document/Trading Partner Agreement (Version 4010A1)
- Part B Form Instructions
- Part B EDI Enrollment Form
- Part B EDI Customer Profile
- Part B MCE User Agreement
General Part B Forms
- Advance Beneficiary Notice (General Use)
- Advance Beneficiary Notice (Laboratory Tests)
- All CMS Forms
- Medicare Secondary Payer Questionnaire
- Notice of Exclusions From Medicare Benefits (NEMB)
- Overpayment Refund
- Offset Request Form
- Publications Order Form
- Redetermination Request (first level of the appeal process)
- Therapy Cap Exception Request (for services rendered prior to January 1, 2007)
- Medicare Part B Reopenings Adjustment Request Form (corrected claim, clerical errors, etc.)
