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Medicare will pay you directly when you complete this form and attach an itemized bill from your doctor or supplier. Your bill does not have to be paid before you submit this claim for payment, but you MUST attach an itemized bill in order for Medicare to process this claim.
Medical services. Purpose. This form is for Sharp Health Plan Medicare members to request medical payment for: Influenza (flu) or pneumococcal vaccinations. Part B services (includes physician, laboratory, imaging services) Durable medical equipment, prosthetics, orthotics and supplies.
Form CMS-1490S (SC) (01/05) EF 02/2005 HOW TO FILL OUT THIS MEDICARE FORM Medicare will pay you directly when you complete this form and attach an itemized bill from your doctor or supplier.
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Medicare will pay you directly when you complete this form and attach an itemized bill from your doctor or supplier. Your bill does not have to be paid before you submit this claim for payment, but you MUST attach an itemized bill in order for Medicare to process this claim.
Patient’s Request for Medical Payment for the Influenza/Pneumococcal Vaccinations, Part B Services, (includes physician, laboratory, imaging services), Durable Medical Equipment, Prosthetics, Orthotics and Supplies, Foreign Travel (including Canada and Mexico) and Shipboard Services.
Patient’s Request for Medical Payment (CMS-1490S) Key Points/Instruction/What you need to know. If a beneficiary wishes to submit a claim, they must complete the CMS-1490S form. They must also attach any bill(s) they received from providers/suppliers.
Thank you for your recent request for the Patient’s Request for Medical Payment form (CMS-1490S). Enclosed is the form, instructions for completing it, and where to return the form for processing. The address where you need to return the form for processing depends on where the service was received. For example: If you received a service in ...
