Information Collection

Request For Enrollment In Supplementary Medical Insurance (smi)

IC 113232 under ICR 199004-0938-004 · OMB 0938-0245.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0245 can be found here:

Documents and Forms

Document Name Document Type

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Information Collection (IC) Details

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IC Title:	REQUEST FOR ENROLLMENT IN SUPPLEMENTARY MEDICAL INSURANCE (SMI)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-4040				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	40,000	40,000
Annual IC Time Burden (Hours)	3,333	3,333
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded

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