PATIENT'S REQUEST FOR MEDICAL PAYMENT (English/Spanish)
O.M.B. Expiration Date
Effective April 1, 2019, only the revised 01-18 version will be accepted for the Form CMS-1490S. The provided link below includes
the form and all the applicable instructions. Please read all instructions prior to submitting a claim to Medicare.
(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.