1490s form 2026

1. Click ‘Get Form’ to open the 1490s form in the editor.
2. In Block 1, enter your name as it appears on your Medicare Card (Last Name, First Name, Middle Name).
3. For Block 2, input your Health Insurance Claim Number exactly as shown on your Medicare card and select the appropriate box for the patient’s sex.
4. In Block 3, provide your mailing address and telephone number. If this is a new address, check the corresponding box.
5. Describe the illness or injury in Block 4. Indicate if it was related to employment or an accident by checking the appropriate boxes.
6. Complete Block 5 if you have additional medical coverage. Provide details about other insurance or assistance programs.
7. Sign and date the form in Block 6. If unable to sign, mark an (X) and have a witness sign as well.

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