Cms 10055 2026

1. Click ‘Get Form’ to open the cms 10055 in the editor.
2. Begin by entering the Skilled Nursing Facility’s Name and Address at the top of the form. Ensure that all contact information, including telephone and TTY/TDD numbers, is accurate.
3. Fill in the 'Date of Notice' field to indicate when this notice is being issued.
4. Review the section detailing items or services that Medicare may not cover. Clearly list these items along with reasons for non-coverage in the designated fields.
5. Provide an estimated cost for these items or services in the 'Estimated Cost' field, and specify any other insurance you may have.
6. Choose one option by checking either 'YES' or 'NO' regarding your decision to receive these items or services. Make sure to date and sign this notice at the bottom.
7. Finally, enter your name and Patient Identification # before submitting your completed form.

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