Form CMS-1490S: Patient's Request for Medical Payment (Medicare Part B Claim Form)
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JustFill is not affiliated with Centers for Medicare & Medicaid Services (CMS) / HHS. This is an independent third-party tool to help you complete Form CMS-1490S. Always download the current blank form from the official source and verify your completed copy before signing or submitting. Official Form CMS-1490S from Centers for Medicare & Medicaid Services (CMS) / HHS
Form CMS-1490S, Patient's Request for Medical Payment (OMB No. 0938-0999), is the official 2-page Medicare beneficiary claim form used when a doctor, supplier, or foreign shipboard/border emergency provider does not file a Medicare Part B claim on your behalf (or does not accept Medicare assignment). You complete Blocks 1–6, attach an itemized bill with CPT/HCPCS procedure and ICD-10 diagnosis codes, and mail it to your state's Medicare Administrative Contractor (MAC). Open the CMS-1490S blank in JustFill to fill it online and download a clean PDF.
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Whenever a Medicare beneficiary pays out-of-pocket for a covered Part B medical service, durable medical equipment (DME), ambulance transport, or qualifying emergency care in Canada/Mexico or aboard a cruise ship — and the provider fails or refuses to submit the electronic 837P / CMS-1500 claim — the patient files Form CMS-1490S ("Patient's Request for Medical Payment") to request direct Medicare reimbursement. JustFill lets Medicare beneficiaries, family caregivers, patient advocates, and non-participating medical offices fill Form CMS-1490S online in any browser, save a clean copy, and print it for mailing to the regional Medicare Administrative Contractor (MAC).
The official Form CMS-1490S PDF (OMB No. 0938-0999) is published free by the Centers for Medicare & Medicaid Services at cms.gov/medicare/cms-forms/cms-forms/downloads/cms1490s-english.pdf. Click "Fill the blank Form CMS-1490S now" above to open the fillable CMS-1490S in JustFill, type Blocks 1–6 in your browser, and download a clean PDF.
What each section of Form CMS-1490S asks for. JustFill’s AI will detect these fields automatically when you upload the PDF — review the breakdown below so you know what to enter.
Enter the patient’s exact name as shown on the red, white, and blue Medicare card (Block 1), the 11-character Medicare Beneficiary Identifier / MBI and Sex (Block 2), and the patient’s current mailing address and telephone number (Block 3).
Describe the illness, injury, or symptoms requiring treatment (Block 4a), and answer Yes/No whether the condition was related to employment (4b), an auto accident or other liability accident (4c), or whether Medicare is primary (4d).
If the patient has other health insurance, Medigap, or employer/union coverage, enter the insurer’s name, policy/group number, and policyholder details so Medicare coordinates benefits accurately.
Signed and dated by the patient (or authorized representative if the patient is physically or mentally unable to sign, accompanied by a representative signature explanation).
A fictional Medicare Part B beneficiary in Florida submits Form CMS-1490S to First Coast Service Options (her regional MAC) to request reimbursement for an outpatient orthopedic evaluation and custom knee brace paid out-of-pocket.
Name: SAMPLE, EVELYN R · Medicare Number (MBI): 1EG4-TE5-MK72 · Sex: ☑ Female · Address: 820 Palm Harbor Blvd, Sarasota, FL 34236 · Phone: (941) 555-0192
Uses the 11-character alphanumeric MBI from the Medicare card (fictional MBI).
4a: Right knee osteoarthritis flare-up requiring diagnostic evaluation and hinged knee orthosis (ICD-10 M17.11) · 4b (Employment): ☑ No · 4c (Auto/Other Accident): ☑ No
☑ No other primary group health insurance (Medigap supplemental policy already linked via Medicare crossover)
Signed: Evelyn R. Sample · Date: 10/23/2026 (Itemized superbill with NPI, CPT 99214 & L1832, and paid receipt attached)
These values are made up. They are here to show what belongs on each line, not to be copied — every name, number, and address on your own Form CMS-1490S has to be your own. Always attach an itemized bill containing CPT/HCPCS codes, ICD-10 diagnosis codes, and the provider’s 10-digit NPI, and mail to the Medicare Administrative Contractor (MAC) for your state.
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By uploading, you confirm you have the legal right to use this document.
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Official source: Form CMS-1490S on Centers for Medicare & Medicaid Services (CMS) / HHS’s website
Edition checked: Form CMS-1490S (OMB No. 0938-0999, Centers for Medicare & Medicaid Services, 2 pages). Verified against the official source on · Verified in our Government Forms Fillability Study.
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