Information Collection

Request for Medicare Payment

IC 44217 under ICR 202601-3220-003 · OMB 3220-0131.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form G-740S (06-18) Patient's Request for Medicare Payment Request for Medicare Payment	Form and Instruction
Form CMS-1500 (02-12) Health Insurance Claim Form Request for Medicare Payment	Form and Instruction
G-740S (06-18) Patient's Request for Medicare Payment Form G-740S (06-18).pdf	Form and Instruction
CMS-1500 (02-12) Health Insurance Claim Form CMS 1500 (02-12).pdf	Form and Instruction
CMS-1490S (01-18).pdf CMS-1490S	IC Document
CMS Workload Report October 2020-September 2021.pdf CMS Workload Report	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 405.424

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	G-740S (06-18)				No		Paper Only
Form and Instruction	CMS-1500 (02-12)				Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: RRB-3, Medicare Part B

FR Citation: 79 FR 58874

Number of Respondents: 1

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	1	1
Annual IC Time Burden (Hours)	1	1
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-1490S		02/27/2019
CMS Workload Report		09/20/2022

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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