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Form CMS-1490 (version 01/18)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PATIENT’S REQUEST FOR MEDICAL PAYMENT
IMPORTANT: PLEASE READ THE ATTACHED INSTRUCTIONS PRIOR TO SUBMITTING A CLAIM TO MEDICARE
SEND ONLY THE COMPLETED FORM TO YOUR MEDICARE ADMINISTRATIVE CONTRACTOR – Include a copy of the
itemized bill and any supporting documents. Make a copy of your claim submission for your records and allow at
least 60 days for Medicare to receive and process your request.
Reference the Medicare Administrative Contractor Address Table for the correct address to mail your claim form.
Medicare will not process a beneficiary request for payment for diabetic test strips, Part B drugs, or for items paid
for under the DMEPOS Competitive Bidding program.
Your reason for submitting this claim: (see the Instructions for additional information, check one box only)
The provider or supplier refused to file a claim for Medicare Covered Services
The provider or supplier is unable to file a claim for the Medicare Covered Services
The provider or supplier is not enrolled with Medicare
IF YOU NEED HELP, CALL 1-800-MEDICARE (1-800-633-4227). TTY USERS SHOULD CALL 1-877-486-2048.
Type of Patient’s Request (see instructions for additional information, check one box only):
Influenza/Pneumococcal Vaccination, Part B (includes physician, laboratory, imaging services), Foreign
Travel (including Canada and Mexico) and/or Shipboard Services
Durable Medical Equipment, Prosthetics, Orthotics and Supplies
PLEASE TYPE OR PRINT INFORMATION
Form Approved OMB
No. 0938-1197
SECTION 1 - PATIENT INFORMATION
Patient’s Name as shown on Medicare Card (Last, First, Middle)
Patient’s Medicare Number exactly as it is shown on the Medicare card:
Date of Birth (mm/dd/yyyy)
Male
Female
Street address (or P.O. Box - include apartment number)
City
State
Zip code
Telephone number
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Form CMS-1490 (version 01/18)
SECTION 2 - INFORMATION ABOUT SERVICES FURNISHED
FOR ALL CLAIMS including I