How to Complete HCFA Forms: Electronic & Paper

The Centers for Medicare and Medicaid Services (CMS), formerly known as the Health Care Financing Administration (HCFA), is largely responsible for the coordination of Medicare and Medicaid public health benefits. The CMS is a federal agency of the United States Department of Health and Human Services (DHHS). The agency oversees and manages the Medicare program, Medicaid benefits, and the State Children's Health Insurance Program (SCHIP). The agency is responsible for ensuring quality health care programs and institutions comply with the Health Insurance Portability and Accountability Act of 1996. Health-care professionals and individuals may request payment for medical services by submitting a medical insurance claim electronically or through the mail.

Things You'll Need

• Form CMS-1490S, Patient's Request for Medical Payment
• Form CMS-10106, Medicare Authorization to Disclose Personal Health Information
• National Provider Identifier (NPI) number
• Medicare number (health insurance claim)
• Itemized bills for each medical service

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Instructions

Electronic Processing

• 1

  File a Medicare claim within one year from the date you received medical services. Visit the CMS website and click on the link "Medicare Online Forms." Search for the link "Patient's Request for Medical Payment" and click on it. Download the CMS-1490S PDF and read the form's instructions and all accompanying materials.

• 2

  Print out the form. Write your name, claim number, mailing address, and telephone number in the corresponding boxes. Write a description of your illness or injury in the corresponding box. Check off additional boxes that may apply.

• 3

  Visit the NPPES website to locate your health care provider's National Provider Identifier (NPI) number. Write this number in block four on the form. Complete all other blocks, sign, and date it.

• 4

  Contact Medicare Beneficiary Services at 1-800-633-4227 for instructions on how to submit the CMS-1490S form online.

Paper Filing

• 5

  File a Medicare claim within one year from the date you received medical services. On the CMS website, click on the link "Medicare Online Forms." Download the CMS-1490S, Patient's Request for Medical Payment. Print out the form, the application instructions, and any other necessary information.

• 6

  Fill out the form. Write your name on the form as it appears on your Medicare card. Write your Health Insurance Claim Number on the form as well. In each block, complete the necessary information. For additional medical insurance, provide the policy number in the appropriate box. Sign your name and date the form.

• 7

  Visit the CMS website again. Download, print, and fill out the CMS-10106 Medicare Authorization to Disclose Personal Health Information document to authorize Medicare to release your health information. Contact 1-800-633-4227 for a printed copy of the form.

• 8

  Attach itemized bills to the back of the CMS-1490S form for each date of medical services. Mail the completed form to the Medicare Carrier in your area responsible for processing your claim. Call 1-800-633-4227 to find out the address of the carrier or refer to one of the addresses in the application instructions PDF.