Information Collection

Request for Enrollment in Supplementary Medical Insurance and Supporting Regulations in 42 CFR 407.10 & 407.11

IC 7901 under ICR 200304-0938-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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

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Information Collection (IC) Details

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IC Title:	Request for Enrollment in Supplementary Medical Insurance and Supporting Regulations in 42 CFR 407.10 & 407.11	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	CMS-4040				Yes	Yes
Form	CMS-4040-SP				Yes	Yes

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

	Approved	Previously Approved
Annual Number of Responses for this IC	10,000	10,000
Annual IC Time Burden (Hours)	2,500	2,500
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.