CMS Forms

Details for CMS 1490S

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Form #	CMS 1490S
Form Title	PATIENT'S REQUEST FOR MEDICAL PAYMENT (English/Spanish)
Revision Date	01/01/2005
O.M.B. #	0938-0008
O.M.B. Expiration Date	05/31/2009
CMS Manual	N/A
Special Instructions	(1) You will need to review the related link below on How/Where to File a Claim; (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.


Downloads
Claim Form: CMS 1490S-ENGLISH Instruction for 1490S: CMS 1490S-English Instructions Part B (except for shipboard, Canada-Mexico, or foreign travel) CMS 1490S-English Instructions DME (except for shipboard, Canada-Mexico, or foreign travel) CMS 1490S-English Instructions Shipboard CMS 1490S-English Instructions Canada-Mexico CMS 1490S-English Instructions Foreign Travel Spanish Claim Form: CMS 1490S-SPANISH Spanish Instructions for 1490S: CMS 1490S-Spanish Instructions-Part B (except for shipboard, Canada-Mexico, or foreign travel) CMS 1490S-Spanish Instructions-DME (except for shipboard, Canada-Mexico, or foreign travel) CMS 1490S-Spanish Instructions-Shipboard CMS 1490S-Spanish Instructions-Canada-Mexico CMS 1490S-Spanish Instructions-Foreign Travel
Related Links Inside CMS
How/Where to File a Claim
Related Links Outside CMS
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