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Printable blank Patient Request for Medical Payment Form CMS-1490S

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1. What is a CMS-1490S Form?

The fillable CMS-1490S Form (full title: Patient’s Request for Medical Payment) is used for collecting the personal information of a patient who needs to request payment for the furnished medical procedures. The request is processed within 60 days from the moment of submission. Additional documentation and the itemized bill are required (see the form for details).

2. What I need the CMS-1490S Form for?

  • Make sure to submit this claim if the provider or supplier refuses or is unable to file a claim for Medicare Covered Services, or is not enrolled with Medicare;
  • Don’t file this form if you need to request diabetic test strips, Part B items, or other items covered by the DMEPOS Competitive Bidding Program.

You can download CMS-1490S Form in PDF format directly from the PDFLiner’s online library. We also provide a free 10-day trial for our editing platform that lets you print complete forms without downloading.

3. How to fill out the CMS-1490S Form?

To fill out this blank properly, include the following information:

  • reason for submitting the claim;
  • type of patient’s request (check the one that suits);
  • Section 1 – patient’s detailed personal information;
  • Section 2 – describe the illness in written form and check what the condition refers to;
  • Section 3 – complete if you are 65+ y.o and match the requirements;
  • Section 4 – sign and date the form together with your witnesses.
  • Leave the informational pages 4-18 for yourself and don’t file them along with the form.

4. Organizations that work with CMS-1490S Form:

  • Department of Health and Human Services;
  • Centers for Medicare and Medicaid Services.

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