Healthcare forms
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California LIC 601: Identification and Emergency Information
California community care facilities keep LIC 601 for each resident, with their contacts, doctors and emergency information.
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California LIC 603A: Resident Appraisal
Residential care facilities for the elderly in California use LIC 603A to assess a resident's needs, functioning and mental condition before admission.
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CMS-10106: Authorization to Disclose Personal Health Information
People with Medicare use CMS-10106 to let Medicare share their personal health information with a person or organization they choose.
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CMS-1696: Appointment of Representative
People with Medicare use CMS-1696 to appoint someone to represent them in a Medicare claim or appeal.
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CMS-40B: Application for Enrollment in Medicare Part B
People who already have Medicare Part A use CMS-40B to enroll in Part B (medical insurance).
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CMS-460: Medicare Participating Physician or Supplier Agreement
Physicians, practitioners and suppliers sign CMS-460 to become Medicare participants, agreeing to accept assignment on all Medicare claims.
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CMS-588: Electronic Funds Transfer (EFT) Authorization Agreement
Medicare providers and suppliers use CMS-588 to have Medicare payments deposited directly into their bank account.
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CMS-855I: Medicare Enrollment Application for Physicians and Non-Physician Practitioners
Physicians and non-physician practitioners use CMS-855I to enroll in Medicare, or to update or revalidate their enrollment.
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Form SSA-827: Authorization to Disclose Information to the Social Security Administration
People applying for Social Security disability benefits sign SSA-827 so the SSA can get their medical and other records.
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VA Form 10-10EZ: Application for Health Benefits
Veterans use VA Form 10-10EZ to apply for VA health care.
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VA Form 21-4142 and 21-4142a: Authorization to Disclose Information to the VA
Veterans use VA Forms 21-4142 and 21-4142a to let the VA request their records from private doctors and hospitals.
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