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Form #
CMS 1490S
Form Title
PATIENT'S REQUEST FOR MEDICAL PAYMENT (English/Spanish)
Revision Date
2005-01-01
O.M.B. #
0938-0999
O.M.B. Expiration Date
2016-05-31
CMS Manual
N/A
Special Instructions
(1) You will need to review the related link below on How to File a Claim Form; (2) print out the CMS 1490S form; and (3) select and print out the applicable instructions. The address for form submission is included in the instructions.