CMS-1490S (Patient's Request for Medical Payment)

CMS-1490S is used by Medicare beneficiaries to file a claim directly in specific situations, such as provider refusal or inability to file. Include service documentation and follow the form instructions before mailing.

Centers for Medicare & Medicaid Services · CMS-1490S · 2021-06-01

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This is the online version of the CMS-1490S form.

Complete the fields below and we'll automatically fill, print, and mail it for you once you finish.

Patient information

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What you need

  • Patient identifying information exactly as shown on the Medicare card
  • Reason for filing the claim directly with Medicare
  • Description of illness or injury and treatment details
  • Itemized bill with service date, charges, and provider details
  • Other insurance information if Medicare is secondary payer
  • Patient signature and date (or witness section if patient cannot sign)
  • Signed form (wet signature required)
  • Itemized bill(s) from provider or supplier (required) — Include itemized bills showing dates of service, charges, and provider details.
  • Primary insurer Explanation of Benefits (EOB) (optional) — Attach if Medicare is secondary payer.

How it works

  1. Fill out the form
  2. Add attachments
  3. Preview the PDF
  4. Mail it

Where it gets mailed

Enter the recipient address during checkout.

Packet order

  • Cover sheet (auto-generated)
  • Completed form PDF
  • Attachments (in the order you upload)

Common mistakes

  • Missing itemized bills or incomplete provider information.
  • Leaving the reason-for-submission boxes unchecked.
  • Omitting other insurance details when secondary coverage exists.
  • Submitting the form without a required signature and date.
  • Mailing to an incorrect Medicare Administrative Contractor address.

FAQs

When should I use CMS-1490S?

Use CMS-1490S when a provider or supplier refused or was unable to file a Medicare claim, or is not enrolled with Medicare, and you need to request payment directly.

What attachments are typically required?

Attach itemized bills and any supporting documents requested in the form instructions. If Medicare is secondary, include your primary insurer's Explanation of Benefits when available.

Where do I mail CMS-1490S?

Mail it to the Medicare Administrative Contractor for your area using the current contractor address table and instructions referenced by Medicare.

Sources

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Last verified

Last Centers for Medicare & Medicaid Services verification: February 20, 2026