Medicare Patient's Request for Payment Form: CMS1490S
The following forms may be used/submitted by patients to receive reimbursement from Medicare for medical services/supplies where the patient paid the cost.
Please send the completed claim form, your itemized bill, and any supporting documents to the appropriate Medicare contractor and explain in detail your reason for submitting the claim. For example, include a statement that notifies the Medicare contractor that your provider or supplier refused or is unable to file a claim for a Medicare-covered service and/or is not enrolled with Medicare.
Doctors, providers, and suppliers are required to submit claims to Medicare when providing covered services. You can reduce your out-of-pocket expense by seeing a doctor or supplier that is enrolled in Medicare and bills Medicare for the services provided.
When you submit your own claim to Medicare, complete the entire form. If you are unable to find the National Provider Identifier (NPI) number, the Medicare contractor will look this up when processing your claim form. However, if the claim form has other incomplete or invalid information, the Medicare contractor will return the claim along with a letter to you clearly stating what information is missing or invalid.
You should mail the original claim form, a copy of the itemized bill, and supporting documents to Medicare. You should make copies of your claim submission for your records. Please allow at least 60 days for Medicare to receive and process your request.
Each of the PDF files in the links below contains a CMS1490S form along with instructions pertinent to the situation in which the medical care/supplies were provided. Choose the form/instructions combination that is appropriate for your situation:
- CMS 1490S-ENGLISH (form only) [PDF, 52KB]
- CMS 1490S-English Form and Instructions Part B [PDF, 90KB]
- CMS 1490S-English Form and Instructions DME [PDF, 66KB]
- CMS 1490S-English Form and Instructions Shipboard [PDF, 83KB]
- CMS 1490S-English Form and Instructions Canada-Mexico [PDF, 77KB]
- CMS 1490S-English Form and Instructions Foreign Travel [PDF, 129KB]
- CMS 1490S-SPANISH (form only) [PDF, 52KB]
- CMS 1490S-Spanish Form and Instructions Part B [PDF, 76KB]
- CMS 1490S-Spanish Form and Instructions DME [PDF, 79KB]
- CMS 1490S-Spanish Form and Instructions Shipboard [PDF, 93KB]
- CMS 1490S-Spanish Form and Instructions Canada-Mexico [PDF, 91KB]
- CMS 1490S-Spanish Form and Instructions Foreign Travel [PDF, 82KB]
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