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What this form is for

Use this form when a Medicare beneficiary needs to request payment for covered medical services under the circumstances described by CMS.

Agency: Centers for Medicare & Medicaid Services

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MedClaimSoftware does not receive the information you type into the form. Save the completed PDF to a location you control.

Before submitting

Follow the current CMS instructions and include required itemized bills or supporting documents. Send only the completed claim pages and required documentation.

Check the current official instructions →

Current file

CMS-1490S — blank official form

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