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.
The forms offered below are in Adobe PDF format. Download a free copy of Acrobat Reader.
General Part B Forms
- Advance Beneficiary Notice
- All CMS Forms
- Overpayment Refund
- Offset Request Form
- Publications Order Form
- Redetermination Request Form
- Reopenings Adjustment Request Form
Provider Enrollment Forms
- Enrollment Applications
- Authorization Agreement For Electronic Funds Transfer
- Participation Agreement
Electronic Data Interchange Forms
Effective 08/01/2008, all EDI forms and correspondence must be submitted to the address and/or fax number below for processing. This includes forms for new setups as well as forms for changes to existing setups. Failure to send the forms to the correct address will result in the application being returned to you.
| Address: | Fax: |
|---|---|
| CIGNA Government Services Attn: EDI Support Services PO Box 690 Nashville TN 37202 |
615.782.4653 |
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.
