Cms-1490s

CMS-1490S (01-18).pdf

Request for Medicare Payment

CMS-1490S

OMB: 3220-0131

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No. 0938-XXXX

PATIENT’S REQUEST FOR MEDICAL PAYMENT
IMPORTANT: PLEASE READ THE ATTACHED INSTRUCTIONS PRIOR TO SUBMITTING A CLAIM TO MEDICARE
SEND ONLY THE COMPLETED FORM TO YOUR MEDICARE ADMINISTRATIVE CONTRACTOR – Include a copy of the
itemized bill and any supporting documents. Make a copy of your claim submission for your records and allow at
least 60 days for Medicare to receive and process your request.
Reference the Medicare Administrative Contractor Address Table for the correct address to mail your claim form.
Medicare will not process a beneficiary request for payment for diabetic test strips, Part B drugs, or for items paid
for under the DMEPOS Competitive Bidding program.
Your reason for submitting this claim: (see the Instructions for additional information, check one box only)
The provider or supplier refused to file a claim for Medicare Covered Services
The provider or supplier is unable to file a claim for the Medicare Covered Services
The provider or supplier is not enrolled with Medicare
IF YOU NEED HELP, CALL 1-800-MEDICARE (1-800-633-4227). TTY USERS SHOULD CALL 1-877-486-2048.
Type of Patient’s Request (see instructions for additional information, check one box only):
Influenza/Pneumococcal Vaccination, Part B (includes physician, laboratory, imaging services), Foreign
Travel (including Canada and Mexico) and/or Shipboard Services
Durable Medical Equipment, Prosthetics, Orthotics and Supplies

PLEASE TYPE OR PRINT INFORMATION

SECTION 1 - PATIENT INFORMATION
Patient’s Name as shown on Medicare Card (Last, First, Middle)

Patient’s Medicare Number exactly as it is shown on the Medicare card:

Date of Birth (mm/dd/yyyy)

Male

Female

Street address (or P.O. Box - include apartment number)

City

State

Zip code

Telephone number

Form CMS-1490S (version 01/18)

SECTION 2 - INFORMATION ABOUT SERVICES FURNISHED
FOR ALL CLAIMS including Influenza and Pneumococcal Vaccinations, describe the illness or injury for which you received treatment.

Attach all supporting documentation to the form including an itemized bill with the following information:
• Date of service
• Place of service
• Description of illness or injury
• Description of each surgical or medical service or supply furnished
• Charge for each service
• The doctor’s or supplier’s name and address
• The provider or supplier’s National Provider Identifier (NPI) If known
IMPORTANT: If the itemized bill is from:
• A Clinical laboratory for ordered tests
• An independent diagnostic imaging center for ordered imaging procedures
• A supplier of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) for ordered DMEPOS
The ordering & referring providers legal name MUST be included on the itemized bill.
Please also include the ordering & referring providers National Provider Identifier (NPI) if known.
Was the condition related to:
Yes

Employment

Yes

Auto Accident

Yes

Treatment for chronic dialysis or kidney transplant

Yes

Other Accident

SECTION 3 - INFORMATION ABOUT HEALTH INSURANCE OTHER THAN MEDICARE
Complete this section if you are age 65 or older and enrolled in a health insurance plan where you or your spouse
are currently working and covered by any medical coverage other than Medicare.
Yes

Are you employed and covered under an employee health plan?

Yes

Is your spouse employed and are you covered under your spouse’s employee health plan?

Yes

Do you have any medical coverage other than Medicare, such as private insurance, MEDIGAP, employment related insurance,
Medicaid,or the Veterans Administration (VA)?

Name of other Medical Insurance

Policy Number including Medicaid ID Number

Policyholder’s Name (Last, First, Middle)

Street Address (or P.O. Box) of other Medical Insurance

City

State

Zip code

Please attach a copy of your primary insurer’s Explanation of Benefits if Medicare is secondary.
Form CMS-1490S (version 01/18)

SECTION 4 - SIGNATURE
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and
it is true and correct to the best of my knowledge. Anyone who misrepresents or falsifies essential information requested by this form may
upon conviction be subject to fine and imprisonment under Federal law.
I authorize any holder of medical or other information about me to release it to the Centers for Medicare & Medicaid Services or its
designated contractor or the Social Security Administration for this Medicare claim. I permit a copy of this authorization to be used in place
of the original, and request payment of medical insurance benefits to me.
Signature of Patient
Date Signed (mm/dd/yyyy)

If you cannot sign your name, mark an (X) on the signature line. Have a witness sign his/her name next to the “X” and complete the section
below.
If signing this form on behalf of a Medicare patient, on the ‘Signature of Patient’ line above, indicate the patient’s name followed by “By” and
sign your name. Provide your name, address, and relationship to the patient with a brief explanation why the patient cannot sign.
Name of Witness (Last, First, Middle)

Street Address

City

State

Zip code

Relationship to the Patient

Signature of Witness

Date Signed (mm/dd/yyyy)

Briefly explain why the Patient cannot sign:

Send the completed form and supporting documentation to your Medicare contractor. Reference the
Medicare Administrative Contractor Address table for the correct address to mail your claim form. If you still
do not know the address of your Medicare contractor, call 1-800-MEDICARE (1-800-633-4227). TTY users
should call 1-877-486-2048.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
valid OMB control number. The valid OMB control number for this information collection is 0938-XXXX. The time required to complete this
information collection is estimated to be XX hours per response, including the time to review instructions, search existing data resources,
gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,
Baltimore, Maryland 21244-1850. DO NOT MAIL APPLICATIONS TO THIS ADDRESS. Mailing your application to this address will significantly
delay application processing.
Form CMS-1490S (version 01/18)

COLLECTION AND USE OF MEDICARE INFORMATION
We are authorized by the Centers for Medicare & Medicaid Services to ask you for information needed in the
administration of the Medicare program. Authority to collect information is in section 205(a), 1872 and 1875 of the
Social Security Act, as amended.
The information we obtain to complete your Medicare claim is used to identify you and to determine your
eligibility. It is also used to decide if the services and supplies you received are covered by Medicare and to insure
that proper payment is made.
The information may also be given to other providers of services, Medicare Administrative Contractor (MAC),
medical review boards, and other organizations as necessary to administer the Medicare program. For example, it
may be necessary to disclose information to a hospital or doctor about the Medicare benefits you have used.

With one exception, which is discussed below, there are no penalties under Social Security law for refusing to
supply information. However, failure to furnish information regarding the medical services rendered or the amount
charged would prevent payment of the claim. Failure to furnish any other information, such as name or Medicare
number, would delay payment of the claim.

It is mandatory that you tell us if you are being treated for a work related injury so we can determine whether
worker’s compensation will pay for the treatment. Section 1877(a)(3) of the Social Security Act provides criminal
penalties for withholding this information. If you are being treated for a work related injury be sure to check the
appropriate box in Section 2 titled ‘Condition Related to’.

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Physicians and other suppliers, such as clinical laboratories, imaging service suppliers, and durable medical
equipment suppliers are required by law to submit a claim for Medicare covered services furnished to you, the
Medicare beneficiary, within one year of the date of service.

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To reduce your out-of-pocket expenses, Medicare beneficiaries should always obtain medical care from physicians
and other suppliers who are enrolled in the Medicare program. If you submit a claim for covered services furnished
by a physician or other supplier who is not enrolled with the Medicare program, your claim may be denied.
For a list of participating Medicare enrolled physicians in your area, please go to www.medicare.gov/physiciancompare
or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If a physician or supplier furnishes Medicare covered services to you and refuses to submit a claim on your behalf
for those services, please call 1-800-MEDICARE (1-800-633-4227) in order to file a complaint with the Medicare
contractor. TTY users should call 1-877-486-2048.

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When you submit your own claim to Medicare, complete the entire form. If the claim form has incomplete or
invalid information, the Medicare contractor will return the claim along with a letter to you clearly stating what
information is missing or invalid.

If the Patient is deceased, please contact your Social Security office for instructions on how to file a claim.

NOTICE: Anyone who misrepresents or falsifies essential information requested by this form may upon conviction
be subject to fine and imprisonment under Federal law. No Part B Medicare benefits may be paid unless this form is
received as required by existing law and regulations (20 CFR 422.510).

Form CMS-1490S (version 01/18)

INSTRUCTIONS
READ BEFORE SUBMITTING A CLAIM TO MEDICARE
(PLEASE RETURN ONLY THE FORM AND NOT THE INSTRUCTION)
Patient’s Request for Medical Payment for the Influenza/Pneumococcal Vaccinations, Part B Services, (includes
physician, laboratory, imaging services), Durable Medical Equipment, Prosthetics, Orthotics and Supplies,
Foreign Travel (including Canada and Mexico) and Shipboard Services

Influenza and Pneumococcal Vaccination:
Medicare may pay for seasonal influenza and pneumococcal vaccinations. Annual Part B deductible and
coinsurance amounts do not apply. Medicare does not pay for the hepatitis B vaccines. All physicians, nonphysician practitioners, and suppliers who administer seasonal influenza vaccinations must take assignment on
the claim for the vaccine.

Part B Services:
In most situations, your physician, other practitioner or supplier will submit your claim to Medicare, if they do not,
you can submit a claim.

Durable Medical Equipment, Prosthetics, Orthotics and Supplies:
In most situations, your supplier of DMEPOS will submit your claim to Medicare, if they do not, you can submit a
claim for an item or services furnished by this supplier.

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Foreign Travel (including Canada and Mexico):
Medicare law prohibits payment for items and services furnished outside the United States except in certain limited
circumstances. The term “outside the U.S.” means anywhere other than the 50 states of the U.S., the District of
Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.

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There are three situations when Medicare may pay for certain types of health care services rendered in a foreign
hospital (a hospital outside the U.S.):
1. You’re in the U.S. when you have a medical emergency and the foreign hospital is closer than the nearest U.S.
hospital that can treat your illness or injury.

2. You’re traveling through Canada without unreasonable delay by the most direct route between Alaska and
another state when a medical emergency occurs, and the Canadian hospital is closer than the nearest U.S.
hospital that can treat your illness or injury. Medicare determines what qualifies as “without unreasonable
delay” on a case-by-case basis.

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3. You live in the U.S. and the foreign hospital is closer to your home than the nearest U.S. hospital that can treat
your medical condition, regardless of whether it’s an emergency.
In these situations, Medicare will pay only for the Medicare-covered services you get in a foreign hospital.

Shipboard Services:

Medicare may pay for medically necessary shipboard services if the services rendered on board a ship in a United
States port, or within 6 hours of when the ship arrived at, or departed from, a United States port, are considered to
have been furnished in United States territorial waters. Services not furnished in a United States port, or within 6
hours of when the ship arrived at, or departed from, a United States port, are considered to have been furnished
outside United States territorial waters, even if the ship is of United States registry. If you had medical services
aboard a ship and the doctor’s office is not in the U.S., then you will need to submit a claim to Medicare. If you had
medical services aboard a ship and the doctor’s office is located in the U.S., the doctor will submit the claim to
Medicare. The term “United States” means the 50 States, the District of Columbia, the Commonwealth of Puerto
Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands, American Samoa and, for purposes of services
rendered on a ship, includes the territorial waters adjoining the land areas of the United States.
For shipboard services please include a copy of the ship’s itinerary.

Form CMS-1490S (version 01/18)

HOW TO FILL OUT THIS MEDICARE FORM
Medicare may pay you directly when you complete this form and attach an itemized bill from your doctor or
supplier. Mail your completed claim form to the Medicare contractor responsible for processing your claim. If you
need additional assistance, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
FOLLOW THESE INSTRUCTIONS CAREFULLY:
A. Your Reason for submitting this Claim
Check the box that applies to this claim
B. Type of Patient’s Request
Check only one box that applies to this claim
Section 1 – PATIENT INFORMATION
• Print your name as shown on your Medicare card (Last Name, First Name, Middle Name).

• Print your Medicare Number exactly as it is shown on the Medicare card.

• Print your date of birth (mm/dd/yyyy)

• Check the appropriate box for the patient’s sex.

• Patient’s Condition related to: Check the appropriate boxes

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Section 2 – INFORMATION ABOUT SERVICES FURNISHED
• Describe the illness or injury for which you received treatment

• Furnish your mailing address and include your telephone number

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NOTE: You must attach an itemized bill in order for Medicare to process this claim.
Attach all supporting documentation to the form including an itemized bill with the following information:
• Charge for each service

• Place of service

• The doctor’s or supplier’s name and address

• Description of illness or injury

• The provider or supplier’s National Provider Identifier (NPI) If known

• Description of each surgical or medical
service or supply furnished

• The ordering & referring Provider's Legal Name if required as
indicated in Section 2

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• Date of service

• It is helpful if the diagnosis is shown on the physician’s itemized bill. If not, be sure you have completed Section
2 of this form.

• Many times a bill will show the names of several doctors or suppliers. It is very important the provider who
treated you be identified. Simply circle his/her name on the bill.

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• Mark out any services on the itemized bill(s) you are attaching for which you have already filed a Medicare
claim.

• Attach a copy of your primary insurer’s Explanation of Benefits notice if you are requesting Medicare Secondary
payment.

• Shipboard services please include a copy of the ship’s itinerary.

Section 3 – INFORMATION ABOUT HEALTH INSURANCE OTHER THAN MEDICARE
• Complete this Section if you are age 65 or older and enrolled in a health insurance plan where you or your
spouse are currently working and if you have any medical coverage other than Medicare.
• Check all boxes that apply
• Name of other Medical Insurance
• Policy Number including Medicaid ID Number
• Policyholder’s Name
• Street Address of other Medical Insurance
Section 4 – SIGNATURE
Sign your name and date the form
If the Medicare beneficiary is not able to sign his/her name, follow the instructions on the form.
Form CMS-1490S (version 01/18)

MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE
FOR INFLUENZA/PNEUMOCOCCAL VACCINATION, PART B (INCLUDES PHYSICIAN, LABORATORY,
IMAGING SERVICES), FOREIGN TRAVEL (INCLUDING CANADA AND MEXICO) AND SHIPBOARD
SERVICES:
Mail your claim form, itemized bill and supporting documents to:

Alabama

Palmetto GBA, LLC
Mail Code: AG-600
P.O. Box 100306
Columbia, SC 29202-3306

Alaska

Noridian Healthcare Solutions, LLC
P.O. Box 6703
Fargo, ND 58108-6703

American Samoa

Noridian Healthcare Solutions, LLC
P.O. Box 6777
Fargo, ND 58108-6777

Arkansas

Novitas Solutions, Inc.
P.O. Box 3098
Mechanicsburg, PA 17055-1816

If you live in:

Noridian Healthcare Solutions , LLC
P.O. Box 6704
Fargo, ND 58108-6704

California Northern
(For Part B)

Noridian Healthcare Solutions
P.O. Box 6774
Fargo, ND 58108-6774

California Southern
(For Part B)

Noridian Healthcare Solutions, LLC
P.O. Box 6775
Fargo, ND 58108-6775

Colorado

Novitas Solutions
P.O. Box 3107
Mechanicsburg, PA 17055-1823

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Arizona

Novitas Solutions, Inc.
Attention: JL Claims Department
2020 Technology Parkway, Suite 100
Mechanicsburg, PA 17050

(Address to send Medicare 1490 claims via Priority mail or through a commercial courier
(UPS, FedEx) for which a PO Box cannot be used, please use the following street address:

(Address to send Medicare 1490 claims via Priority mail or through a
commercial courier (UPS, FedEx) for which a PO Box cannot be used, please use the
following street address:
Novitas Solutions, Inc.
Attention: JL Claims Department
2020 Technology Parkway, Suite 100
Mechanicsburg, PA 17050

Connecticut

National Government Services, Inc.
P.O. Box 6178
Indianapolis, IN 46206-6178

Delaware

Novitas Solutions
P.O. Box 3397
Mechanicsburg, PA 17055-1842

Florida

First Coast Service Options, Inc.
P.O. Box 2525
Jacksonville, FL 32231-0019

Form CMS-1490S (version 01/18)

Mail your claim form, itemized bill and supporting documents to:

Georgia

Palmetto GBA, LLC
Mail Code: AG-600
P.O. Box 100306
Columbia, SC 29202-3306

Guam

Noridian Healthcare Solutions, LLC

P.O. Box 6777
Fargo, ND 58108-6777
Hawaii

Noridian Healthcare Solutions, LLC

Idaho

P.O. Box 6777
Fargo, ND 58108-6777
Noridian Healthcare Solutions, LLC

National Government Services, Inc.

Illinois

P.O. Box 6701
Fargo, ND 58108-6701

Indiana

P.O. Box 6475
Indianapolis, IN 46206-6475
Wisconsin Physicians Service

Wisconsin Physicians Service

Iowa

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P.O. Box 8940
Madison, WI 53708-8940

Wisconsin Physicians Service

P.O. Box 7238
Madison, WI 53707-7238

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Kansas

P.O. Box 8550
Madison, WI 53708-8550

CGS Administrators, LLC
P.O. Box 20019
Nashville, TN 37202

Louisiana

Novitas Solutions, Inc.
P.O. Box 3097
Mechanicsburg, PA 17055-1815

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Kentucky

(Address to send Medicare 1490 claims via Priority mail or through a commercial courier
(UPS, FedEx) for which a PO Box cannot be used, please use the following street address:

Maine

Novitas Solutions, Inc.
Attention: JL Claims Department
2020 Technology Parkway, Suite 100
Mechanicsburg, PA 17050

Maryland

National Government Services, Inc.
P.O. Box 6178
Indianapolis, IN 46206-6178
Novitas Solutions, Inc.
P.O. Box 3398
Mechanicsburg, PA 17055-1843
(Address to send Medicare 1490 claims via Priority mail or through a commercial courier
(UPS, FedEx) for which a PO Box cannot be used, please use the following street address:
Novitas Solutions, Inc.
Attention: JL Claims Department
2020 Technology Parkway, Suite 100
Mechanicsburg, PA 17050

Form CMS-1490S (version 01/18)

Massachusetts

National Government Services, Inc.
P.O. Box 6178
Indianapolis, IN 46206-6178

Michigan

Wisconsin Physicians Service
P.O. Box 8987
Madison, WI 53708-8987

Minnesota

National Government Services, Inc.
P.O. Box 6475
Indianapolis, IN 46206-6475

Mississippi

Novitas Solutions
P.O. Box 3129
Mechanicsburg, PA 17055-1834

If you live in:

(Address to send Medicare 1490 claims via Priority mail or through a commercial courier
(UPS, FedEx) for which a PO Box cannot be used, please use the following street address:

Wisconsin Physicians Service
P.O. Box 14260
Madison, WI 53708-0260

Montana

Noridian Healthcare Solutions, LLC
P.O. Box 6735
Fargo, ND 58108-6735

Nebraska

Wisconsin Physicians Service
P.O. Box 8667
Madison, WI 53708-8667

Nevada

Noridian Healthcare Solutions, LLC
P.O. Box 6776
Fargo, ND 58108-6776

New Hampshire

National Government Services, Inc.
P.O. Box 6178
Indianapolis, IN 46206-6178
Novitas Solutions
P.O. Box 3129
Mechanicsburg, PA 17055-1834

New Jersey

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Missouri

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Novitas Solutions, Inc.
Attention: JL Claims Department
2020 Technology Parkway, Suite 100
Mechanicsburg, PA 17050

(Address to send Medicare 1490 claims via Priority mail or through a commercial courier
(UPS, FedEx) for which a PO Box cannot be used, please use the following street address:
Novitas Solutions, Inc.
Attention: JL Claims Department
2020 Technology Parkway, Suite 100
Mechanicsburg, PA 17050

Form CMS-1490S (version 01/18)

Mail your claim form, itemized bill and supporting documents to:

New Mexico

Novitas Solutions
P.O. Box 3129
Mechanicsburg, PA 17055-1834
(Address to send Medicare 1490 claims via Priority mail or through a commercial courier
UPS, FedEx) for which a PO Box cannot be used,please use the following street address:

Noridian Healthcare Solutions, LLC
P.O. Box 6706
Fargo, ND 58108-6706

Northern Mariana
Islands

Noridian Healthcare Solutions
P.O. Box 6777
Fargo, ND 58108-6777

Ohio

CGS Administrators, LLC
P.O. Box 20019
Nashville, TN 37202

Oklahoma

Novitas Solution
P.O. Box 3129
Mechanicsburg, PA 17055-1834

North Dakota

Palmetto GBA, LLC
Mail Code: AG-600
P.O. Box 100190
Columbia, SC 29202-3190

North Carolina

National Government Services, Inc.
P.O. Box 6178
Indianapolis, IN 46206-6178

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New York

Novitas Solutions, Inc.
Attention: JL Claims Department
2020 Technology Parkway, Suite 100
Mechanicsburg, PA 17050

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(Address to send Medicare 1490 claims via Priority mail or through a commercial courier
(UPS, FedEx) for which a PO Box cannot be used, please use the following street address:

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Oregon

Novitas Solutions, Inc.
Attention: JL Claims Department
2020 Technology Parkway, Suite 100
Mechanicsburg, PA 17050

Pennsylvania

Noridian Healthcare Solutions
P.O. Box 6702
Fargo, ND 58108-6702
Novitas Solutions
P.O. Box 3129
Mechanicsburg, PA 17055-1834
(Address to send Medicare 1490 claims via Priority mail or through a commercial courier
(UPS, FedEx) for which a PO Box cannot be used, please use the following street address:
Novitas Solutions, Inc.
Attention: JL Claims Department
2020 Technology Parkway, Suite 100
Mechanicsburg, PA 17050

Form CMS-1490S (version 01/18)

Puerto Rico

First Coast Service Options, Inc.
P. O. Box 45036
Jacksonville, Florida 32232-5036

Rhode Island

National Government Services, Inc.
P.O. Box 6178
Indianapolis, IN 46206-617

South Carolina

Palmetto GBA, LLC
Mail Code: AG-600
P.O. Box 100190
Columbia, SC 29202-3190

South Dakota

Noridian Healthcare Solutions, LLC
P.O. Box 6707
Fargo, ND 58108-6707

Tennessee

Palmetto GBA, LLC
Mail Code: AG-600
P.O. Box 100306
Columbia, SC 29202-3306

Texas

Novitas Solutions
P.O. Box 3129
Mechanicsburg, PA 17055-1834

If you live in:

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(Address to send Medicare 1490 claims via Priority mail or through a commercial courier
(UPS, FedEx) for which a PO Box cannot be used, please use the following street address:
Novitas Solutions, Inc.
Attention: JL Claims Department

Noridian Healthcare Solutions
P.O. Box 6725
Fargo, ND 58108-6725

Vermont

National Government Services, Inc.
P.O. Box 6178
Indianapolis, IN 46206-6178

Virginia

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Utah

2020 Technology Parkway, Suite 100
Mechanicsburg, PA 17050

Palmetto GBA, LLC
Mail Code: AG-600
P.O. Box 100190
Columbia, SC 29202-3190
First Coast Service Options, Inc.
P. O. Box 45098
Jacksonville, Florida 32232-5098

Washington

Noridian Healthcare Solutions
P.O. Box 6700
Fargo, ND 58108-6700

West Virginia

Palmetto GBA, LLC
Mail Code: AG-600
P.O. Box 100190
Columbia, SC 29202-3190

Virgin Islands

Form CMS-1490S (version 01/18)

Wisconsin

National Government Services, Inc.
P.O. Box 6475
Indianapolis, IN 46206-647

Wyoming

Noridian Healthcare Solutions
P.O. Box 6708
Fargo, ND 58108-6708

If you live in:

FOR DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS AND SUPPLIES (DMEPOS) ONLY
Return your form and supporting documentation to:

Connecticut, Delaware, District of Columbia, Maine,
Maryland, Massachusetts, New Hampshire, New
Jersey, New York, Pennsylvania, Rhode Island, Vermont

Noridian JA DME
P.O. Box 6727
Fargo, ND 58108-6727

Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio,
Wisconsin Indianapolis, IN 46207-7027

CGS Administrators, LLC
P.O. Box 20010
Nashville, TN 37202-001

Alabama, Arkansas, Colorado, Florida, Georgia,
Louisiana, Mississippi, New Mexico, North Carolina,
Oklahoma, Puerto Rico, South Carolina, Tennessee,
Texas, U.S. Virgin Islands, Virginia, West Virginia

CGS Administrators, LLC
P.O. Box 20010
Nashville, TN 37202-001

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If you live in:

Noridian JD DME
P.O. Box 6727
Fargo, ND 58108-6727

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Alaska, American Samoa, Arizona, California, Guam,
Hawaii, Idaho, Iowa, Kansas, Missouri, Montana,
Nebraska, Nevada, North Dakota, Northern Mariana
Islands, Oregon, South Dakota, Utah, Washington,
Wyoming

Form CMS-1490S (version 01/18)

File Type	application/pdf
File Title	1490S-Patient's Request for Medical Payment
Author	Centers for Medicare & Medicaid Services
File Modified	2018-03-22
File Created	2018-01-18