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Form #
CMS 1490S
Form Title
PATIENT'S REQUEST FOR MEDICAL PAYMENT (English/Spanish)
Revision Date
2018-01-01
O.M.B. #
0938-1197
O.M.B. Expiration Date
2020-03-31
CMS Manual
N/A
Special Instructions
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.