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)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1197 can be found here:

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-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 CMS-1490S_English.pdf Form and Instruction
CMS-1490s Patient Request for Medical Payment (Spanish) CMS-1490S_Spanish.pdf Form and Instruction
CMS-1490s Patient Request for Medical Payment (Spanish) CMS-1490S_Spanish.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	CMS-1500 (02-12)/CMS-1490S	Agency IC Tracking Number:	OIT

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 424, Section C (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-1500(02-12)	Claim Form	Sample 1500_2012_02.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-1490s	Patient Request for Medical Payment	CMS-1490S_English.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-1490s	Patient Request for Medical Payment (Spanish)	CMS-1490S_Spanish.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Medicare Multi-Carrier Claims System (MCS)	FR Citation: 83 FR 6591

Number of Respondents: 2,451,781	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 99 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	975,664,249	-58,175,657	1,033,839,906
Annual IC Time Burden (Hours)	17,163,310	-1,684,190	18,847,500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.