Tax FormsFillable tax forms simplify and speed up your tax filing process and aid with recordkeeping.Explore all templatesReal EstateReal estate templates for all cases, from sale to rentals, save you a lot of time and effort.Explore all templatesInsuranceInsurance templates make it easier for agents to manage policies and claims.Explore all templatesLegalLegal templates provide a structured foundation for creating legally binding documents.Explore all templatesMedicalMedical forms help you keep patient documentation organized and secure.Explore all templatesBill of SaleBill of Sale templates streamline the transfer of ownership with clarity and protection.Explore all templatesContractsVarious contract templates ensure efficient and clear legal transactions.Explore all templatesEducationEducational forms and templates enhance the learning experience and student management.Explore all templates
FeaturesThe all-in-one document management system has all the features you need to safely and efficiently handle your PDFs. Dive in, learn how to use all the tools, and become a PDF pro.Explore all featuresShare PDFWith the help of PDFliner you can share your PDF files by email or via the link as soon as you have edited, filled, or signed them online.Sign PDFPDFLiner gives the opportunity to sign documents online, save them, send at once by email or print. Register now, upload your document and e-sign it onlineFill Out PDFPDFLiner provides different tools for filling in PDF forms. All you need is to register, upload the necessary document and start filling it out.Draw on a PDFDraw lines, circles, and other drawings on PDF using tools of PDFLiner online. Streamline your document editing process, speeding up your productivity
- Log in
- Sign Up
Get your Patient Request for Medical Payment Form CMS-1490S in 3 easy steps
01 Fill and edit template
02 Sign it online
03 Export or print immediately
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.
Fillable online Patient Request for Medical Payment Form CMS-1490S