Get Medicare 1490s Form

The Medicare 1490s Form, also known as the Patient's Request for Medical Payment, allows users to request payment for medical services covered by Medicare. This guide offers clear, step-by-step instructions on how to complete the form online effectively.

Follow the steps to fill out the Medicare 1490s Form online.

1. Click ‘Get Form’ button to obtain the Medicare 1490s Form and open it in the online editor.
2. In Block 1, enter your name exactly as it appears on your Medicare card, including your last name, first name, and middle name.
3. In Block 2, type your Health Insurance Claim Number, including the letter at the end, just as it is shown on your Medicare card. Check the appropriate box for the patient's sex.
4. Provide your mailing address in Block 3, ensuring to include the street address, city, state, zip code, and a telephone number in Block 3b.
5. In Block 4, describe the illness or injury for which you received treatment. Select the appropriate options in Blocks 4b and 4c regarding employment or accident-related conditions.
6. Complete Block 5a if you are age 65 or older and enrolled in a health insurance plan from your workplace. In Block 5b, complete it if your spouse is covered under their workplace health plan. Fill in Block 5c if you have any other medical coverage and provide the necessary policy information.
7. Sign your name in Block 6. If you are unable to sign, make an (X) and have a witness sign their name and address in Block 6 as well, explaining your relationship to the patient.
8. In Block 6b, print the date you completed the form.
9. Attach all necessary itemized bills from your healthcare provider to the back of the form. Ensure that these bills contain the required information for Medicare processing.
10. Once the form is completed and signed, save your changes, download, print, or share the form as needed, and mail it to the appropriate Medicare contractor address.

Complete your Medicare 1490s Form online today to ensure your medical claims are processed efficiently.