1490S Patient’s Request for Medical Payment

Medicare Form Summary

You’ll need the 1490S form if your doctor does not file a claim for you and you need to file it yourself

What you’ll need:

• Name, Medicare number, and address
• Description of the service or medical item
• Itemized bill containing the following information:
◦ Date of service
◦ Place of service
◦ Description of service
◦ Charge for service
◦ Name and address of your doctor
◦ Diagnosis

Other important information:

• You must file a claim within one calendar year from the date of service.

Mail completed form and itemized bill to your state’s Medicare Administrative Contractor (MAC). You can find the address for your MAC by calling Medicare at 1-800-MEDICARE (1-800-633-4277).

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