Get 1490s-part B Claim Form.doc. Qualified Electronic Health Record (ehr) Direct Vendors

This guide provides essential steps for completing the 1490S-Part B Claim Form for Medicare reimbursement. Users will find clear instructions to ensure smooth submission and processing of their claims.

Follow the steps to successfully fill out the claim form.

1. Click the ‘Get Form’ button to access the 1490S-Part B Claim Form for filling out online. This action opens up the form in your digital editor, allowing you to input your information.
2. In Block 1, enter the name as it appears on your Medicare card, ensuring to include last name first, followed by first and middle names. This should be typed or printed clearly.
3. In Block 2, provide your Health Insurance Claim Number exactly as it appears on your Medicare card. Make sure to check the appropriate box indicating your sex.
4. Fill in Block 3 with your mailing address, including street address, city, state, and zip code, along with your telephone number in Block 3b. Indicate if this is a new address.
5. In Block 4, describe the illness or injury for which you received treatment. Check the relevant boxes in Blocks 4b and 4c regarding the condition's relation to employment or an accident.
6. Complete Block 5 for any additional insurance coverage you may have. Provide the name and address of the other insurance, along with the policy or medical assistance number if applicable.
7. In Block 6, sign the form. If you are unable to sign, mark an 'X' and have a witness sign their name and address. Ensure to include the date you completed the form in Block 6b.
8. Attach the itemized bills from your doctor or supplier to the back of the claim form. These bills must include details such as dates of services, descriptions of services rendered, charges for each service, and the name of the treating physician or supplier.
9. After completing all sections, review the form for accuracy, and keep a copy for your records before submitting. Ensure to send the completed claim, itemized bill, and supporting documents to the correct Medicare contractor according to the service location.

Complete your documents online today to ensure timely Medicare reimbursement.