Forms & Links for Psych

CMS Evaluation & Management Guidelines

www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf​

Psychiatric Examination

/uploads/1/3/9/4/13946264/outreach-and...pdf

Psych Insurance Verification Form

insurance_verification_form.doc​

Outpatient Auth Request for Optum Medi-Cal

www.optumsandiego.com/content/sandiego/en/county-staff---providers/fee-for-service-providers.html

Forms & Links for General Use

2021 Financial Hardship Form

​financial_hardship_waiver_2021.doc​

Sample Face Sheet & Policy Statement

/uploads/1/3/9/4/13946264/face_sheet_and_policy_statement.doc

W-9 Form

www.irs.gov/pub/irs-pdf/fw9.pdf​

Medicare ABN Form

​abnenglish2023v508.pdf

Medicare Opt Out Forms
opt-out_affidavit.pdf

med.noridianmedicare.com/documents/10525/2052366/Opt-Out+Private+Contract​
​opt-out_private_contract.pdf

Link to Jennifer Kirschenbaum - Attorney https://www.kirschenbaumesq.com/page/healthcare

Link to CMS MACRA

www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/macra-mips-and-apms/macra-mips-and-apms.html

Forms & Links for Medicine

Transitional Care Management FAQ Sheet

www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf

CMS Evaluation & Management Guidelines

www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf

Sample Inpatient Charge Sheet

/uploads/1/3/9/4/13946264/inpatient_charge_sheet__snf.xls