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)

Documents and Forms

Document Name Document Type
Form CMS-1490S CMS-1500 (02-12)/CMS-1490S Form
CMS-1490S Health Insurance Common Claim Form (Spanish) CMS-1490S_English.pdf Form
CMS-1490 English Health Insurance Common Claims Form CMS-1490S_English.pdf Form
CMS-1500 CMS-1500 sample Sample 1500_2012_02.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	CMS-1490S	Health Insurance Common Claim Form (Spanish)	CMS-1490S_English.pdf	Yes	Yes	Fillable Fileable
Form	CMS-1490 English	Health Insurance Common Claims Form	CMS-1490S_English.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-1500	CMS-1500 sample	Sample 1500_2012_02.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: 2,507,992	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 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	998,032,912	22,368,663	975,664,249
Annual IC Time Burden (Hours)	17,329,912	166,602	17,163,310
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.