Cms-1500 (02-12)/cms-1490s

Health Insurance Common Claims Form and Supporting Regulations at 42 CFR Part 424, Subpart C (CMS-1500 and CMS-1490S)

OMB: 0938-1197

IC ID: 204966

Information Collection (IC) Details

View Information Collection (IC)

CMS-1500 (02-12)/CMS-1490S OIT
 
No Modified
 
Mandatory
 
42 CFR 424, Section C  (To search for a specific CFR, visit the Code of Federal Regulations.)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-1500(02-12) Claim Form CMS1500.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-1490s Patient Request for Medical Payment CMS1490S-ENGLISH.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-1490s Patient Request for Medical Payment (Spanish) CMS1490S-Spanish.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

2,029,505 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   99 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,033,839,906 0 30,407,915 0 0 1,003,431,991
Annual IC Time Burden (Hours) 18,847,500 0 -971,156 0 0 19,818,656
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Non-Substantive Change CMS-1409S (0938-1197).Justification of Non-substantive Change.pdf 11/29/2019
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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