Request for Medicare Payment

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0131 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-1500 (02-12) Request for Medicare Payment Form and Instruction
G-740S (03-13) Patient's Request for Medicare Payment Form G-740S (03-13).pdf Form and Instruction
CMS-1500 (02-12) Health Insurance Claim Form CMS 1500 (02-12).pdf Form and Instruction
CMS-1490S (1-2005).pdf CMS-1490S IC Document
CMS Workload Report 2014-2015.pdf CMS Workload Report IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Request for Medicare Payment	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 405.424

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-1500 (02-12)	Health Insurance Claim Form	CMS 1500 (02-12).pdf		Yes	Yes	Fillable Fileable Signable
Form and Instruction	G-740S (03-13)	Patient's Request for Medicare Payment	Form G-740S (03-13).pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: RRB-3, Medicare Part B	FR Citation: 79 FR 58874

Number of Respondents: 1	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1	1
Annual IC Time Burden (Hours)	1	1
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-1490S	CMS-1490S (1-2005).pdf	09/23/2009
CMS Workload Report	CMS Workload Report 2014-2015.pdf	03/25/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.