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Step 1 of 5Centers for Medicare & Medicaid Services · CMS-1490S · 2021-06-01

CMS-1490S Customer-Assembly Preparation Kit

This workflow helps you prepare a Medicare patient request for medical payment when a provider or supplier did not file the claim. PostalForm prepares the official form and delivers the unsigned preparation kit only to your verified address. PostalForm does not file, serve, or submit it. Hand-sign and date the patient certification, add the itemized bill and any required insurance records, use the current Medicare Administrative Contractor address table, and mail the final claim yourself.

Prepare CMS-1490S for your own final assembly and submission

PostalForm prepares and prints an unsigned customer-assembly kit and sends it only to your verified address. You perform final assembly and submission.

Preparation and delivery record only — not proof of filing or agency receipt
Current step
Patient information
Patient name, Medicare number, and Date of birth
This step
9 fields · 9 required

PostalForm is not affiliated with Centers for Medicare & Medicaid Services.

Step 1

Patient information

Patient name, Medicare number, and Date of birth

9 required
Sex *

Need more context?

The form is ready to fill now. If you want supporting instructions, mailing notes, or source links, they are below.

Important details+

Answer the guided questions and PostalForm prepares the official form, leaves signature areas blank, adds a customer instruction cover, and sends the packet only to your verified address. Nothing is filed or submitted for you. Hand-sign and date the patient certification, add the itemized bill and any required insurance records, use the current Medicare Administrative Contractor address table, and mail the final claim yourself.

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)
  • Hand-sign the printed form after the preparation kit is delivered
  • 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) — Only needed if you have other insurance that paid first. Attach the Explanation of Benefits from that insurer.
Form summary+

This workflow helps you prepare a Medicare patient request for medical payment when a provider or supplier did not file the claim. PostalForm prepares the official form and delivers the unsigned preparation kit only to your verified address. PostalForm does not file, serve, or submit it. Hand-sign and date the patient certification, add the itemized bill and any required insurance records, use the current Medicare Administrative Contractor address table, and mail the final claim yourself.

How it works+
  1. Answer the guided questions and review the prepared form information.
  2. PostalForm prints the official form with signature areas left blank and sends the customer-assembly kit only to your verified address.
  3. After delivery, follow the cover instructions, hand-sign where required, and add every original, certified record, payment, witness, certification, companion form, or other physical item.
  4. Verify the current deadline and destination, then personally complete final submission through the official channel.
Where it gets mailed+

PostalForm mails the unsigned preparation kit to you. You complete the signatures, physical enclosures, and final submission yourself.

Packet order+
  • Customer assembly instruction cover (remove and keep before final submission)
  • Prepared unsigned form (signature and reserved third-party fields blank)
  • Printed reference attachments
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+
Related+
Last verified+

Last Centers for Medicare & Medicaid Services verification: July 12, 2026