- Form #
- CMS 1490S
- Form Title
- PATIENT'S REQUEST FOR MEDICAL PAYMENT (English/Spanish)
- Revision Date
- 01/01/2005
- O.M.B. #
- 0938-0999
- O.M.B. Expiration Date
- 11/30/2010
- CMS Manual
- N/A
- Special Instructions
- (1) You will need to review the related link below on How to File a Claim Form; (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
- CMS 1490S-ENGLISH [PDF, 52KB]
- CMS 1490S-English Instructions Part B [PDF, 71KB]
- CMS 1490S-English Instructions DME [PDF, 66KB]
- CMS 1490S-English Instructions Shipboard [PDF, 76KB]
- CMS 1490S-English Instructions Canada-Mexico [PDF, 72KB]
- CMS 1490S-English Instructions Foreign Travel [PDF, 76KB]
- CMS 1490S-SPANISH [PDF, 52KB]
- CMS 1490S-Spanish Instructions-Part B [PDF, 85KB]
- CMS 1490S-Spanish Instructions-DME [PDF, 79KB]
- CMS 1490S-Spanish Instructions-Shipboard [PDF, 90KB]
- CMS 1490S-Spanish Instructions-Canada-Mexico [PDF, 85KB]
- CMS 1490S-Spanish Instructions-Foreign Travel [PDF, 90KB]
