Information Collection

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

IC 204966 under ICR 202309-0938-007 · OMB 0938-1197.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.