CMS · Official form

Form CMS-1490S, Patient Request for Medical Payment

When a provider or supplier will not file a Medicare claim for you, Form CMS-1490S is how you claim the payment yourself: your details, what you were charged, and the itemized bill attached.

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What is CMS-1490S?

Form CMS-1490S, Patient Request for Medical Payment, lets a Medicare beneficiary file a claim directly. It is the exception path: providers are normally required to file claims for you, so this form mostly appears when equipment or services came from a non-participating supplier, care was received outside normal channels, or a provider refuses or fails to bill Medicare within the time limit.

The completed form goes to the Medicare claims office for your state (addresses are listed in the form package) together with the itemized bill showing the provider, the services with codes if available, and the charges.

Who files CMS-1490S?

Medicare beneficiaries whose provider or supplier will not file the claim
People claiming for covered services from certain non-enrolled or foreign-travel scenarios where Medicare rules allow
Representatives filing for a beneficiary, with signature authority documented

How to fill out CMS-1490S

Fill in your name, Medicare number, and address exactly as on your Medicare card.
Describe the illness or injury the services treated, and answer the employment and other-insurance questions.
Attach the itemized bill from the provider: it, not the form, carries the services and charges.
Sign, date, and mail everything to the Medicare address for your state listed in the form instructions.

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Page 1 15 fields

Patient's Request for Medical Payment. Important: Please read the attached instructions prior to submitting a claim to Medicare. Send only

The provider or supplier is unable to file a claim for the Medicare Covered Services

The provider or supplier is not enrolled with Medicare

Please type or print information. Section 1 - Patient Information. Patient's Name as shown on Medicare Card (Last, First, Middle)

Patient's Medicare Number exactly as it is shown on the Medicare card.

Date of Birth (mm/dd/yyyy)

Male

Female

Street address (or P.O. Box - include apartment number)

City

State

Zip Code

Telephone Number

Type of Patient’s Request (see instructions on Page 5 for additional information, check one box only). Influenza/Pnuemococcal Vaccination,

Durable Medical Equipment, Prosthetics, Orthotics and Supplies. Note: Please see page 12 for the Addresses to mail your Claim form.

Page 2 23 fields

Section 2 - For all claims including influenza and Pneumococcal Vaccinations, describe the illness or injury for which you received

The provider or supplier's National Provider Identifier (NPI) if known

Yes

Auto Accident? Yes.

Yes

Treatment for chronic dialysis or kidney transplant? Yes.

Yes

Other Accident? Yes.

Yes

Section 3- Information about Health Insurance Other Than Medicare. Complete this section if you are age 65 or older and enrolled in a

Yes

Is your spouse employed and are you covered under your spouse's employee health plan? Yes.

Yes

Do you have any medical coverage other than Medicare, such as private insurance, MEDIGAP. employment related insurance, Medicaid, or the

Yes

Name of other Medical Insurance

Policy Number including Medicaid ID Number

Policyholder's Name (Last, First, Middle)

Street Address or P.IO. Box) or other Medical Insurance

Zip Code

City

State

Condition related to: Employment? Yes.

Page 3 9 fields

Date Signed (mm/dd/yyyy)

If signing this form on behalf of a Medicare patient, on the ‘Signature of Patient’ line above, indicate the patient’s name followed by

Street Address

State

City

Zip code

Relationship to the Patient

Date signed (mm/dd/yyyy)

Briefly explain why the Patient cannot sign

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Frequently asked questions

When would I ever need to file my own Medicare claim?

Rarely. Providers must generally file for you within a year of the service. Use this form when that has not happened and the time limit is approaching, or in the narrow cases where self-filing is the designed route.

Where do I send the completed form?

To the Medicare Administrative Contractor for your state. The address list ships inside the CMS-1490S package, or call 1-800-MEDICARE to confirm.

Form CMS-1490S, Patient Request for Medical Payment

What is CMS-1490S?

Who files CMS-1490S?

How to fill out CMS-1490S

Quick fill CMS-1490S on this page

Frequently asked questions

Related forms

Form CMS-1500, Health Insurance Claim Form

Form CMS-40B, Application for Enrollment in Medicare Part B

Form SSA-44, Medicare Income-Related Monthly Adjustment Amount, Life-Changing Event