Forms and Resources

Rheumatology Enrollment Form

Rheumatology Patient Authorization and Agreement Form

To enroll or conduct a Benefits Review, please visit this site from your desktop computer.

Blank CMS-1500 Form

Blank UB-04/CMS-1450 Form

Office Support Tools

Patient Benefits Information Form

Medical Necessity Template Letter*

Prior Authorization Denial/Redetermination Appeal Template Letter*

Commercial Claim Denial Appeal/Redetermination Template Letter*

Open Access Template Letter*

*Template letters are provided as examples of potential correspondence.

Medicare Redetermination Request Form (Form CMS-20027)

Medicare Reconsideration Request Form (Form CMS-20033)

Request for a Medicare Hearing by an Administrative Law Judge (Form CMS-20034A/B)

Medicare Appointment of Representative Form (Form CMS-1696)

Understanding Your Healthcare Benefits

Patient Brochure

Patient Reimbursement Process Map

Kidney Transplant Enrollment Form

Kidney Transplant Patient Authorization and Agreement Form

To enroll or conduct a Benefits Review, please visit this site from your desktop computer.

Blank CMS-1500 Form

Blank UB-04/CMS-1450 Form

Patient Benefits Information Form

Medical Necessity Template Letter*

Prior Authorization Denial/Redetermination Appeal Template Letter*

Commercial Claim Denial Appeal/Redetermination Template Letter*

My BMS Cases User’s Guide

*Template letters are provided as examples of potential correspondence.

Medicare Redetermination Request Form (Form CMS-20027)

Medicare Reconsideration Request Form (Form CMS-20033)

Request for a Medicare Hearing by an Administrative Law Judge (Form CMS-20034A/B)

Medicare Appointment of Representative Form (Form CMS-1696)

Understanding Your Healthcare Benefits

Patient Brochure

Patient Reimbursement Process Map