SEND ONLY THE COMPLETED FORM TO YOUR MEDICARE ADMINISTRATIVE CONTRACTOR – Include a copy of the itemized bill and any supporting documents. Make a copy of your claim submission for your records and allow at least 60 days for Medicare to receive and process your request.
CMS 1490S | CMS - Centers for Medicare & Medicaid Services
Jun 1, 2021 · (1) The Form CMS-1490S is fillable, can be completed online, printed then mailed. (2) Mail the completed form and itemized bills to the correct Medicare Administrative Contractor as indicated on pages 7 through 18 of the instructions.
CMS 1490S: Patient’s Request For Medical Payment | CMS
Provide your name, address, and relationship to the patient with a brief explanation why the patient cannot sign. Note: Download your information to PDF before printing. Send the completed form and supporting documentation to your Medicare contractor.
Mail your completed claim form to the Medicare Carrier responsible for processing your claim. If you do not know the address of your carrier, call 1-800-MEDICARE (1-800-633-4227).
Other Forms - Medicare
Patient Request for Medical Payment (CMS-1490S) What’s it used for? Filing a claim when you get services and/or supplies (if your provider doesn’t file it).
Forms, Publications, & Mailings - Medicare
Get Medicare forms for different situations, like filing a claim or appealing a coverage decision. Read, print, or order free Medicare publications in a variety of formats. Find out what to do with Medicare information you get in the mail. By checking this box, you consent to …
Mail your completed claim form to the Medicare Carrier responsible for processing your claim. If you do not know the address of your carrier, call 1-800-MEDICARE (1-800-633-4227).
CMS Forms List | CMS - Centers for Medicare & Medicaid Services
Jan 1, 2006 · The following provides access and/or information for many CMS forms. You may also use the "Search" feature to more quickly locate information for a specific form number or form title.
CMS-1490s Patient Request for Medical Payment - OMB 0938-1197
Sep 27, 2023 · Form CMS-1490S (version 01/18) 5 HOW TO FILL OUT THIS MEDICARE FORM Medicare may pay you directly when you complete this form and attach an itemized bill from your doctor or supplier. Mail your completed claim form to the Medicare contractor responsible for processing your claim.
Form CMS-1490S (SC) (01/05) EF 02/2005 HOW TO FILL OUT THIS MEDICARE FORM Medicare will pay you directly when you complete this form and attach an itemized bill from your doctor or supplier.