Document Type |
Form No. |
Form Name |
Instrument File |
URL |
Available Electronically? |
Can Be Submitted Electronically? |
Electronic Capability |
Other-Maternity Care Narrative |
|
|
Maternity-Care-Narrative-05-05-22.pdf
|
|
Yes |
No |
Printable Only |
Other-Diabetes 2 Narrative |
|
|
SBC_Diabetes-Narrative-051222 508.pdf
|
|
Yes |
No |
Printable Only |
Other-Uniform Glossary Anchor |
|
|
Uniform-Glossary-051222 508.pdf
|
|
Yes |
No |
Printable Only |
Other-What the Plan Covers and What You Pay (No Answers) |
|
|
English_Why This Matters NO Answers_Final_11.01.24 (clean).docx
|
|
Yes |
No |
Printable Only |
Other-Why This Matters for SBC (Yes Answers) |
|
|
English_Why This Matters YES Answers_Final_11.01.24 (clean).docx
|
|
Yes |
No |
Printable Only |
Instruction |
|
|
Group-Instructions-051222 508.pdf
|
|
Yes |
No |
Printable Only |
Instruction |
|
|
Individual-Instructions-051222 508.pdf
|
|
Yes |
No |
Printable Only |
Other-Completed SBC Template |
|
|
English_Sample_Completed_SBC_Final_01.28.25 (clean).docx
|
|
Yes |
No |
Fillable Fileable |
Other-SBC Template |
|
|
English_Sample-Completed-SBC-Accessible-Format_Final_11.01.24 (clean).docx
|
|
Yes |
No |
Fillable Fileable |
Other-Foot Fracture Narrative |
|
|
Foot-Fracture-Narrative-051222 508.pdf
|
|
Yes |
No |
Printable Only |
Instruction |
|
|
Coverage-Examples-Calculator-Instructions-051222 508.pdf
|
|
Yes |
No |
Printable Only |
Other-Coverage Calculator |
|
|
Coverage-Examples-Calculator-Instructions-051222 508.pdf
|
|
Yes |
No |
Fillable Printable |
Other-Template |
|
|
Having-a-Baby-Guide-051222 508.pdf
|
|
Yes |
No |
Printable Only |
Other-Diabetes Guide |
|
|
Managing-Type-2-Diabetes-Guide-051222 508.pdf
|
|
Yes |
No |
Printable Only |
Other-Glossary Anchor |
|
|
Uniform-Glossary-051222 508.pdf
|
|
Yes |
No |
Printable Only |
Other-Template |
|
|
Simple-Fracture-Guide-051222 508.pdf
|
|
Yes |
No |
Printable Only |
Instruction |
|
|
English_AIAN-Limited-Cost-Sharing_Final_01.28.25 (clean).docx
|
|
Yes |
No |
Printable Only |
Instruction |
|
|
English_AIAN-Zero-Cost-Sharing_Final_01.28.25 (clean).docx
|
|
Yes |
No |
Printable Only |
Other-Uniform Glossary |
|
|
English_Uniform Glossary_Final_11.01.24 (clean).docx
|
|
Yes |
No |
Printable Only |
Form |
CMS-10407 |
SBC Template
|
SBC-Template-Accessible-Format.pdf
|
|
Yes |
Yes |
Fillable Fileable |
Other-SBC Template - Carolinian |
|
|
Carolinian_SBC-Template-Standard-Format_Final_11.01.24 (clean).docx
|
|
Yes |
No |
Printable Only |
Other-Uniform Glossary - Carolinian |
|
|
Carolinian_Uniform Glossary_Final_11.01.24 (clean).docx
|
|
Yes |
No |
Printable Only |
Other-Why This Matters NO Answers - Carolinian |
|
|
Carolinian_Why this Matters NO Answers_Final_11.01.24 (clean).docx
|
|
Yes |
No |
Printable Only |
Other-Why This Matters - Yes Answers - Carolinian |
|
|
Carolinian_Why this Matters YES Answers_Final_11.01.24 (clean).docx
|
|
Yes |
No |
Printable Only |
Other-SBC Template - Chamorro |
|
|
Chamorro_SBC-Template-Standard-Format_Final_01.28.25 (clean).docx
|
|
Yes |
No |
Printable Only |
Other-Uniform glossary - Chamorro |
|
|
Chamorro_Uniform Glossary_Final_11.01.24 (clean).docx
|
|
Yes |
No |
Printable Only |
Other-Why This Matters No Answers - Chamorro |
|
|
Chamorro_Why this Matters NO Answers_Final_11.01.24 (clean).docx
|
|
Yes |
No |
Printable Only |
Other-Why This Matters YES Answers - Chamorro |
|
|
Chamorro_Why this Matters YES Answers_Final_11.01.24 (clean).docx
|
|
Yes |
No |
Printable Only |
Other-SBC Template - Chinese |
|
|
Chinese_SBC-Template-Standard-Format_01.28.25 (clean).docx
|
|
Yes |
No |
Printable Only |
Other-Uniform Glossary - Chinese |
|
|
Chinese_Uniform Glossary_Final_11.01.24 (clean).docx
|
|
Yes |
No |
Printable Only |
Other-Why This Matters NO Answers - Chinese |
|
|
Chinese_Why This Matters No Answers_Final_11.01.24 (clean).docx
|
|
Yes |
No |
Printable Only |
Other-Why This Matters Yes Answers - Chinese |
|
|
Chinese_Why This Matters Yes Answers_Final_11.01.24 (clean).docx
|
|
Yes |
No |
Printable Only |
Other-SBC Template - Pennsylvania Dutch |
|
|
Pennsylvania Dutch_SBC-Template-Standard-Format_Final_11.01.24 (clean).docx
|
|
Yes |
No |
Printable Only |
Other-Uniform Glossary - Pennsylvania Dutch |
|
|
Pennsylvania Dutch_Uniform Glossary_Final_11.01.24 (clean).docx
|
|
Yes |
No |
Printable Only |
Other-Why This Matters No Answers - Pennsylvania Dutch |
|
|
Pennsylvania Dutch_Why this Matters NO Answers_Final_11.01.24 (clean).docx
|
|
Yes |
No |
Printable Only |
Other-Why This Matters YES Answers - Pennsylvania Dutch |
|
|
Pennsylvania Dutch_Why this Matters YES Answers_Final_11.01.24 (clean).docx
|
|
Yes |
No |
Printable Only |
Other-SBC Template - Samoan |
|
|
Samoan_SBC-Template-Standard-Format_Final_11.01.24 (clean).docx
|
|
Yes |
No |
Printable Only |
Other-Uniform Glossary - Samoan |
|
|
Samoan_Uniform Glossary_Final_11.01.24 (clean).docx
|
|
Yes |
No |
Printable Only |
Other-Why This Matters No Answers - Samoan |
|
|
Samoan_Why this Matters NO Answers_Final_11.01.24 (clean).docx
|
|
Yes |
No |
Printable Only |
Other-Why This Matters Yes Answers |
|
|
Samoan_Why this Matters YES Answers_Final_11.01.24 (clean).docx
|
|
Yes |
No |
Printable Only |
Other-SBC Template - Spanish |
|
|
Spanish_SBC-Template-Standard-Format__Final_11.01.24 (clean).docx
|
|
Yes |
No |
Printable Only |
Other-Uniform Glossary - Spanish |
|
|
Spanish_Uniform Glossary_Final_11.01.24 (clean).docx
|
|
Yes |
No |
Printable Only |
Other-Why This Matters No Answers - Spanish |
|
|
Spanish_Why This Matters No Answers_Final_11.01.24 (clean).docx
|
|
Yes |
No |
Printable Only |
Other-Why This Matters Yes Answers - Spanish |
|
|
Spanish_Why This Matters Yes Answers__Final_11.01.24 (clean).docx
|
|
Yes |
No |
Printable Only |
Other-Why This Matters Yes Answers - Spanish |
|
|
Spanish_Why This Matters Yes Answers__Final_11.01.24 (clean).docx
|
|
Yes |
No |
Printable Only |
Other-SBC Template - Tagalog |
|
|
Tagalog_SBC-Template-Standard-Format_Final_11.01.24 (clean).docx
|
|
Yes |
No |
Printable Only |
Other-Uniform Glossary - Tagalog |
|
|
Tagalog_Uniform Glossary_Final_11.01.24 (clean).docx
|
|
Yes |
No |
Printable Only |
Other-Why This Matters No Answers - Tagalog |
|
|
Tagalog_Why This Matters No Answers_Final_11.01.24 (clean).docx
|
|
Yes |
No |
Printable Only |
Other-Why This Matters Yes Answers - Tagalog |
|
|
Tagalog_Why This Matters Yes Answers_Final_11.01.24 (clean).docx
|
|
Yes |
No |
Printable Only |
Other-SBC Template Standard Format - Navajo |
|
|
Navajo_SBC-Template-Standard-Format_Final_01.07.25 (clean).docx
|
|
Yes |
No |
Printable Only |
Other-Why This Matters NO Answers - Navajo |
|
|
Navajo_Why This Matters NO Answers_Final_01.07.25.docx
|
|
Yes |
No |
Printable Only |
Other-Why This Matters YES Answers - Navajo |
|
|
Navajo_Why This Matters YES Answers_Final_01.07.25.docx
|
|
Yes |
No |
Fillable Fileable |
Other-Uniform Glossary - Navajo |
|
|
Navajo_Uniform Glossary_formatted_Final_01.07.25.docx
|
|
Yes |
No |
Printable Only |