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

Forms and Documents

Document Name	Status
Form CMS-4040 Request for Enrollment in Supplementary Medical Insurance and Supporting Regulations in 42 CFR 407.10 & 407.11 Form	Modified
CMS-4040-OMBsst2006..doc Supporting Statement A	2006-12-28

IC Document Collections

IC ID	Document Title	Status
7901	Request for Enrollment in Supplementary Medical Insurance and Supporting Regulations in 42 CFR 407.10 & 407.11 Form	Modified

ICR Details

OMB Control No: 0938-0245	ICR Reference No: 200701-0938-015
Status: Historical Active	Previous ICR Reference No: 200304-0938-004
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Request for Enrollment in Supplementary Medical Insurance and Supporting Regulations in 42 CFR 407.10 & 407.11
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/06/2007
	Date Received in OIRA: 01/23/2007
Terms of Clearance: Pursuant to OMB Memorandum dated May 22, 2007 (M-07-16) and the Identity Theft Task Force, steps should be taken to reduce the risks of data breach incidents of personally identifiable information. This Paperwork Reduction Act collection requests the Social Security Number (SSN) of individual beneficiaries. OMB is approving this information collection for 18 months to allow CMS to gather information concerning the use and need of individual SSNs. Upon resubmission of the information collection to OMB, please provide a written explanation of the following: 1. Authority for collecting the SSN (e.g. statutory requirement or other legal requirement). 2. Explanation for the use of the SSN on the form (e.g. identity verification, etc.) 3. Alternative method(s) (other than the use of a SSN) for verifying the identity of an individual for the purposes of carrying out the information collection requirement. 4. The cost and systems redesign that would be required to remove the use of the SSN and implement the alternate method(s) of verifying individual identities. This analysis should estimate costs to the program each year over 5 years.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2008	36 Months From Approved	06/30/2007
Responses	10,000	0	10,000
Time Burden (Hours)	2,500	0	2,500
Cost Burden (Dollars)	0	0	0

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Abstract: The form CMS 4040 is used to establish entitlement to Supplementary Medical Insurance (Part B) by individuals ineligible for Hospital Insurance (Part A under Title XVIII of the Social Security Act. The CMS-4040SP is also included in this renewal.

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Authorizing Statute(s): US Code: 42 USC 1395o Name of Law: Every individual who-
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 60532	10/13/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 77026	12/22/2006
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Request for Enrollment in Supplementary Medical Insurance and Supporting Regulations in 42 CFR 407.10 & 407.11	CMS-4040, CMS-4040 SP	Request For Enrollment in Supplementary Medical Insurance ,   Peticion Para Inscribirse En El Seguro Medico Suplementario

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	10,000	10,000	0	0	0	0
Annual Time Burden (Hours)	2,500	2,500	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $63,448

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 01/04/2007

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