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Medicare Forms

CMS Beneficiary Notice Initiative (BNI)
Both Medicare beneficiaries and providers have certain rights and protections related to financial liability under the Fee-for-Service (FFS) Medicare and Medicare Advantage (MA) programs. These financial liability and appeal rights and protections are communicated to beneficiaries through notices given by providers. Use the link above to be directed to these notices.

New Hampshire Medicaid Forms

NH Medicaid Admission Notice

NH Medicaid Continued Stay Notice

NH Medicaid Late Admission Notice

NH Medicaid Preadmission Notice

Colorado Long Term Care Forms

Colorado PASARR Assessment - CPA (PDF)

Colorado PASARR Assessment - CPA (Word)

Depression Diversion Screen (Word)

Geriatric Depression Screen (PDF)

HBU Pre-Eligibility Screening Tool (PDF)

HBU Pre-Eligibility Screening Tool (Word)

Hospital Back Up/Technologically Dependent & Medically Complex Program Application

OBRA PreAdmission Evaluation (PDF)

OBRA PreAdmission Evaluation (Word)

PAR 5615 Form (PDF)

PASRR Billing Form Fy1213 (PDF)

PASRR Billing Form Fy1213 (Word)

PASRR Fax Cover Sheet (PDF)

PASRR Fax Cover Sheet (Word)

PASRR Level 1 (PDF)

PASRR Level 1 (Word)

PASRR Status Change (Word)

PASRR Transfer Form 806