Information Collection

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

IC 7901 under ICR 200701-0938-015 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form CMS-4040 Request for Enrollment in Supplementary Medical Insurance and Supporting Regulations in 42 CFR 407.10 & 407.11	Form
CMS-4040 Request For Enrollment in Supplementary Medical Insuranc CMS-4040.pdf	Form
CMS-4040 SP Peticion Para Inscribirse En El Seguro Medico Suplementa CMS-4040SP.pdf	Form

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: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 407.10 42 CFR 407.11

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-4040	Request For Enrollment in Supplementary Medical Insurance	CMS-4040.pdf		Yes	Yes	Paper Only
Form	CMS-4040 SP	Peticion Para Inscribirse En El Seguro Medico Suplementario	CMS-4040SP.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

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: 100 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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