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

Documents and Forms

Document Name Document Type
Form CMS-1500(02-12) CMS-1500 (02-12)/CMS-1490S Form and Instruction
CMS-1500(02-12) Claim Form Sample 1500_2012_02.pdf Form and Instruction
CMS-1490s Patient Request for Medical Payment CMS-1490S_English.pdf Form and Instruction
CMS-1490s Patient Request for Medical Payment (Spanish) CMS-1490S_Spanish.pdf Form and Instruction