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Patients request for medicare payment Form: What You Should Know

Medicare Application Medicare Supplement Payment Card Purchaser will receive a Medical Payment Card issued by CMS to the primary beneficiary of the health plan. CMS 1490S Patient's Request for Payment Medicare will pay you directly when you complete this form and attach an itemized bill from your doctor or supplier. It is a serious situation. You want to make sure you understand what you need to do. You can: Pay your share of the bill directly to the provider or provider group (if you paid), and pay the bill directly to Medicare. You must file a request to Medicare to verify that you paid the provider directly. Medicare can pay your share via Medicare Supplemental Payment Card. You must not send cash by mail. You must submit cash via a secure way (bank order, wire transfer, etc.) You must file these claims by fax to CMS. Furthermore, you can also fax the medical records to the CMS Customer Support Center: 800-MEDICARE (1-800-  CMS 1490S: Patient's Request for Medical Payment Once a year, the CMS Customer Support Center will send you a Request for Payment (CMS-1490S) form (PDF, 35 KB) to use to verify payment by Medicare. Please note that the CMS Customer Support Center won't help you or answer your questions regarding your reimbursement. Please use our contact form (PDF) to report a suspected non-payment. (The Customer Support Center will also not answer your questions about your reimbursement.) The information you are about to submit is confidential, and it will not be passed on to anyone. This form must be posted to the Health Care Provider Portal, the Medicare Provider Portal, if you are a Medicare Provider (e.g., a hospital, doctor's office, health clinic), and the Electronic Health Record (EHR) by 11:59pm on November 1st of each year prior to the next reporting period. You need to file this form prior to 12:59am on the filing date shown on page 1 of the form. If you received a Med PAC decision regarding the non-payment of your claim, you need to file a complete copy of the Med PAC's decision with Medicare.

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