CMS-1490S

PATIENT'S REQUEST FOR MEDICAL PAYMENT (English/Spanish)

Agency
CMS
Revision
01/18
Fillable fields
49
Pages
18
Official source
CMS form page
Checked
October 20, 2026
Fill CMS-1490S online
Page 1 of form CMS-1490S

Form CMS-1490S: Patient's Request for Medical Payment

Form CMS-1490S, the Patient's Request for Medical Payment, is the Centers for Medicare & Medicaid Services form a person with Medicare uses to submit their own claim. The form gives three reasons to use it: the provider or supplier refused to file a claim for Medicare covered services, is unable to file one, or is not enrolled with Medicare.

It covers influenza and pneumococcal vaccinations, Part B services including physician, laboratory and imaging services, durable medical equipment, prosthetics, orthotics and supplies (DMEPOS), foreign travel including Canada and Mexico, and shipboard services. The form says Medicare will not process a beneficiary request for payment for diabetic test strips, Part B drugs, or items paid for under the DMEPOS Competitive Bidding program.

The form goes to a Medicare Administrative Contractor with an itemized bill. The CMS page says that since April 1, 2019, only the revised 01-18 version is accepted. You can fill it out free in your browser on this page and download the result without an account.

Top of page 1 of Form CMS-1490S: Patient's Request for Medical Payment, as printed by CMS

What's on Form CMS-1490S

Reason and type of request

One box for the reason for the claim, and one box for the type: vaccinations, Part B, foreign travel and shipboard services together, or DMEPOS.

Section 1: patient information

Name and Medicare Number exactly as shown on the Medicare card, date of birth, sex, mailing address and telephone number.

Section 2: services furnished

A description of the illness or injury treated, and yes or no boxes on whether the condition was related to employment, an auto accident, chronic dialysis or kidney transplant, or another accident.

Section 3: other health insurance

For patients 65 or older in a plan where they or their spouse are working, questions on employee health plans and other coverage such as Medigap, Medicaid or the VA, with the insurer's name, policy number and address.

Section 4: signature

The patient signs and dates a declaration under penalty of perjury and an authorization to release information for the claim. A witness section is used when the patient marks an X.

Instructions and address table

Pages 4 to 6 explain each claim type and how to fill out the form. Pages 7 to 18 list Medicare Administrative Contractor addresses. The instructions say to return only the form.

How to file Form CMS-1490S

  1. 1

    Check the reason and type

    Check one box for why you are submitting the claim and one box for the type of request.

  2. 2

    Complete Sections 1 to 3

    Copy your name and Medicare Number exactly as shown on your Medicare card, describe the illness or injury, and answer the other insurance questions if they apply.

  3. 3

    Attach an itemized bill

    The bill shows the date and place of service, the illness or injury, each service or supply with its charge, and the doctor's or supplier's name, address and NPI if known. For lab, imaging or DMEPOS bills, the form says the ordering and referring provider's legal name has to be on it.

  4. 4

    Add other supporting papers

    Circle the provider who treated you if the bill lists several, mark out services already claimed, and attach the primary insurer's Explanation of Benefits if Medicare is secondary, or the ship's itinerary for shipboard services.

  5. 5

    Sign and date it

    Sign Section 4. If you cannot sign, mark an X on the signature line and have a witness sign and complete the witness section.

  6. 6

    Mail it to the right contractor

    Find the address in the table for your type of request, mail the form with the bill and documents, and keep a copy. The form says to allow at least 60 days.

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Where to mail it and what to expect

Finding the address

The Medicare Administrative Contractor Address Table on pages 7 to 18 is split by type of request. For vaccinations and Part B services it goes by the state where the service was received. For DMEPOS, foreign travel and shipboard services it goes by the state where the patient lives.

Priority mail and couriers

Some entries in the table also give a street address for Priority mail or a commercial courier such as UPS or FedEx, where a PO Box cannot be used.

Still not sure

The form says to call 1-800-MEDICARE (1-800-633-4227) if you still do not know the address of your Medicare contractor. TTY users should call 1-877-486-2048.

Processing time

The form says to keep a copy and allow at least 60 days for Medicare to receive and process the request. A claim with incomplete or invalid information is returned with a letter stating what is missing or invalid.

Not the Baltimore address

The CMS address in the Paperwork Reduction Act notice is for comments on the form. The form says mailing an application there will significantly delay processing.

Related forms

Who uses Form CMS-1490S?

  • Provider or supplier refused to file

    A patient whose provider or supplier refused to file a claim for Medicare covered services.

  • Provider or supplier unable to file

    A patient whose provider or supplier is unable to file a claim for the Medicare covered services.

  • Provider or supplier not enrolled

    A patient who got services from a provider or supplier not enrolled with Medicare. The form notes that a claim for covered services from a physician or supplier who is not enrolled may be denied.

  • Someone signing for the patient

    If the patient cannot sign, the person signing writes the patient's name followed by "By" and signs, then gives their name, address, relationship and why the patient cannot sign.

The form asks the patient to check one reason for submitting the claim.

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Questions about Form CMS-1490S

When is Form CMS-1490S used?

The form lists three reasons: the provider or supplier refused to file a claim for Medicare covered services, is unable to file one, or is not enrolled with Medicare. The patient checks one.

What won't Medicare process on this form?

The form says Medicare will not process a beneficiary request for payment for diabetic test strips, Part B drugs, or items paid for under the DMEPOS Competitive Bidding program.

Do I need an itemized bill?

Yes. The instructions say Medicare needs an itemized bill attached to process the claim, showing the date and place of service, each service with its charge, and the doctor's or supplier's name and address.

Where do I mail Form CMS-1490S?

To the Medicare Administrative Contractor listed in the address table on pages 7 to 18, by state and type of request. If you still do not know the address, the form says to call 1-800-MEDICARE (1-800-633-4227).

How long does Medicare take to process it?

The form says to allow at least 60 days for Medicare to receive and process your request, and to keep a copy of your claim submission.

Which version of Form CMS-1490S is accepted?

The CMS page says that since April 1, 2019, only the revised 01-18 version is accepted. The form's pages are marked version 01/18.

What if the patient has died?

The instructions say to contact your Social Security office for instructions on how to file a claim.

Do I send the instruction pages too?

No. The instructions say to return only the form and not the instructions, along with the itemized bill and supporting documents.