Forms
Welcome to the DME MAC Jurisdiction C forms section. As forms are identified and updated for Jurisdiction C, we will post them to this section.
The forms offered below are in Adobe PDF format. 
Download a free copy of Acrobat Reader.
- ADMC Request (114K)
- CSI/ELGB User ID Access Request Form (103K)
- CMS Signature Requirements (151K)
- CMS Signature Requirements (151K)
- Corrective Action Plan (147K)
- Electronic Funds Transfer (EFT) Authorization Agreement (74K)
- Intermittent Urinary Catheterization (32K)
- Medicare Secondary Payer (MSP) Questionnaire (43K)
- Offset Request Form (42K)
- PECOS Physicians Letter (36K)
- Physician
Documentation Request Letter (37K)
- Publication Order Form (23K)
- Reconsideration Request Form (28K)
- Redetermination Request Form (152K)
- Reopening Request Form (138K) (Note: If you experience problems opening this form, right click on the link and save the form to your desktop or other location prior to opening it.)
- Suggested Intake Form (27K)
- Voluntary Overpayment Refund (105K)
