The CMS-1490S is the Patient's Request for Medicare Payment. Medicare beneficiaries can use this form when billing for Medicare covered services. Providers and suppliers are required by law to submit claims on behalf of the beneficiary, but if the beneficiary wishes to file the claim, they must do so on the CMS-1490S claim form. The beneficiary must also attach to the CMS-1490S any bill(s) they receive from providers/suppliers.
This form is on the CMS website
(PDF, 52 KB). Completed CMS-1490S forms for Part B services should be sent to:
P.O. Box 10066
Augusta, Georgia 30999