Form CMS-1490S Medicare Claim Form for Patients: Edit Online Free & Download PDF
Medicare Claim Form for Patients: Patient's Request for Medical Payment
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Form CMS-1490S in short
Form CMS-1490S is how a person with Original Medicare files their own claim, usually after paying a doctor or supplier who did not bill Medicare. Medicare.gov says you should only need it in rare cases, because the law requires providers to file claims. You send it with an itemized bill to the Medicare contractor for your state.
| Issued by | Centers for Medicare & Medicaid Services (CMS), U.S. Department of Health and Human Services |
|---|---|
| Current version | Version 01/18 (checked 2026-10-25) |
| Who fills it in | A person with Original Medicare whose provider or supplier refused to file, could not file, or is not enrolled in Medicare. Someone can sign for the patient by writing the patient's name, then 'By' and their own signature, with an explanation. |
| Who receives it | The Medicare Administrative Contractor for the state, chosen from the address table in the form. |
| Where to send it | Mail the form, the itemized bill and supporting documents to the Medicare Administrative Contractor listed for your state in the address table on pages 7 to 18. There are separate tables for Part B services and vaccines, for medical equipment and supplies, and for foreign travel and shipboard services. If you are unsure of the address, the form says to call 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048. |
| Deadline | Medicare.gov says Medicare claims must be filed no later than 12 months after the date of service unless an exception applies. The form says to allow at least 60 days for Medicare to receive and process your request. |
| Official links | Official page · Official PDF |
What changed
The form prints version 01/18. CMS says that since April 1, 2019, only the 01/18 version is accepted.
How to fill out Form CMS-1490S, line by line
| Top of page 1 | Reason for the claim Check one: the provider or supplier refused to file, is unable to file, or is not enrolled with Medicare. |
| Top of page 1 | Type of request Check one: vaccines, Part B services, foreign travel or shipboard services, or medical equipment and supplies (DMEPOS). This also decides which address table you use. |
| Section 1 | Patient information Name and Medicare Number exactly as on the Medicare card, date of birth, sex, address and phone. |
| Section 2 | Services and condition Describe the illness or injury and say whether it was related to employment, an auto accident, dialysis or a kidney transplant, or another accident. Attach the itemized bill. |
| Section 3 | Other health insurance Complete if you are 65 or older and covered by a job-based or other plan. Give the insurer, policy number and policyholder. Attach the other insurer's Explanation of Benefits if Medicare pays second. |
| Section 4 | Signature Sign and date. If you sign with an X, a witness signs and gives their name, address and relationship to you. |
Common mistakes to avoid
- Sending it without an itemized bill. The instructions say Medicare needs one to process the claim.
- Using an itemized bill that lacks the ordering provider's legal name for lab tests, imaging or medical equipment. The form says it must be on the bill.
- Checking more than one box for the reason or type of request. The form says to check one box only.
- Sending it to the wrong contractor. Use the address table for your state and the type of service.
- Filing for diabetic test strips, Part B drugs or competitive bidding items. The form says Medicare will not process patient requests for those.
- Sending the instruction pages. The form says to send only the completed form and supporting documents.
- Using it for a Medicare Advantage or Part D plan. Medicare.gov says pharmacies and in-network providers usually file with your plan.
Questions about Form CMS-1490S
When do I need Form CMS-1490S?
Medicare.gov says only in rare cases, because the law requires your doctor, provider or supplier to file Original Medicare claims. Use it if they refuse to file, cannot file, or are not enrolled with Medicare.
What do I send with Form CMS-1490S?
The completed form, an itemized bill, any supporting documents, and, as Medicare.gov suggests, a letter explaining why you are filing the claim yourself.
Where do I mail Form CMS-1490S?
To the Medicare Administrative Contractor for your state, from the address table in the form. Call 1-800-MEDICARE if you are not sure.
How long do I have to file a Medicare claim?
Medicare.gov says claims must be filed no later than 12 months after the date of service unless an exception applies.
Can Medicare pay for care I got outside the U.S.?
The form says Medicare law generally prohibits it, with limited exceptions, such as when a foreign hospital is closer than the nearest U.S. hospital that can treat you.
How long does processing take?
The form says to allow at least 60 days for Medicare to receive and process your request.
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Checked against the official sources on 2026-10-25. PDF Editor Hub is not affiliated with the Centers for Medicare & Medicaid Services or any government agency. This page is general information, not legal or tax advice.