Information Collection

Patient's Request for Medicare Payment

IC 224927 under ICR 201612-0938-001 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-1490s Patient's Request for Medicare Payment	Form
CMS-1490s Patient Request for Medical Payment CMS-1490S-English-090116.pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-1490s	Patient Request for Medical Payment	CMS-1490S-English-090116.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 167,839

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	167,839	167,839
Annual IC Time Burden (Hours)	83,920	83,920
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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