Official Federal Forms > Centers For Medicare And Medicaid Services
SSO Request For Carrier Or Intermediary Assistance CMS-1938 - Official Federal Forms
| SSO Request For Carrier Or Intermediary Assistance Form. This is a national form and can be used in Centers For Medicare And Medicaid Services . |
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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 1. DATE CARRIER OR INTERMEDIARY USE SSO Request For Carrier or Intermediary Assistance 2. BENEFICIARY NAME a. SEX 2.b. HEALTH INSURANCE CLAIM NUMBER 2.c. PHONE NO. M F 3. ADDRESS OF BENEFICIARY 4. NAME AND ADDRESS OF INQUIRER 4.a. PHONE NO. IF OTHER THAN BENEFICIARY 4.b. RELATIONSHIP TO 5. NAME OF WE (If different from beneficiary) BENEFICIARY 6. TO (Assisting carrier or intermediary) 7.a. REQUESTING OFFICE ADDRESS (Send thru parallel SSO unless direct contact permitted) 7.b. PARALLEL OFFICE ADDRESS PART 1 SSO REQUEST 8. DESCRIPTION OF SERVICES (Do not complete if EOMB is attached.) PHYSICIAN/SUPPLIER DATE(S) OF 8.a. (Show full name and address) 8.b. SERVICE 8.c. TYPE/PLACE OF SERVICE 8.d.AMOUNT DATE CLAIM SUBMITTED 9. FURNISH STATUS 10. FOLLOW UP TO ORIGINAL REQUEST OF CLAIM 11. REMARKS OR FURNISH THE FOLLOWING INFORMATION (Attach copy of EOMB or show intermediary control number if pertinent.) 12. PLEASE REPLY TO: BENEFICIARY INQUIRER REQUESTING OFFICE PARALLEL OFFICE PART 2 CARRIER OR INTERMEDIARY REPLY (Return through parallel SSO unless direct return is permitted.)13. REPLY (Continue on reverse side if necessary) OR IS ATTACHED. Form CMS-1938 (U2) (1-88) 1 CARRIER OR INTERMEDIARY <<<<<<<<<********>>>>>>>>>>>>> 2DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 1. DATE CARRIER OR INTERMEDIARY USE SSO Request For Carrier or Intermediary Assistance 2. BENEFICIARY NAME a. SEX 2.b. HEALTH INSURANCE CLAIM NUMBER 2.c. PHONE NO. M F 3. ADDRESS OF BENEFICIARY 4. NAME AND ADDRESS OF INQUIRER 4.a. PHONE NO. IF OTHER THAN BENEFICIARY 4.b. RELATIONSHIP TO BENEFICIARY 5. NAME OF WE (If different from beneficiary) 6. TO (Assisting carrier or intermediary) 7.a. REQUESTING OFFICE ADDRESS (Send thru parallel SSO unless direct contact permitted) 7.b. PARALLEL OFFICE ADDRESS PART 1 SSO REQUEST 8. DESCRIPTION OF SERVICES (Do not complete if EOMB is attached.) DATE(S) OF PHYSICIAN/SUPPLIER 8.a. (Show full name and address) 8.b. TYPE/PLACE OF SERVICE AMOUNT SERVICE 8.c. 8.d. DATE CLAIM SUBMITTED 9. FURNISH STATUS 10. FOLLOW UP TO ORIGINAL REQUEST OF CLAIM 11. REMARKS OR FURNISH THE FOLLOWING INFORMATION (Attach copy of EOMB or show intermediary control number if pertinent.) 12. PLEASE REPLY TO: BENEFICIARY INQUIRER REQUESTING OFFICE PARALLEL OFFICE PART 2 CARRIER OR INTERMEDIARY REPLY (Return through parallel SSO unless direct return is permitted.)13. REPLY (Continue on reverse side if necessary) ORIS ATTACHED. Form CMS-1938 (U2) (1-88) 2 PARALLEL SSO
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