Application for Hospital Insurance and Supporting Regulations in 42 CFR 406.6, 406.7,406.10,406.11 and 406.20

Application for Hospital Insurance

OMB: 0938-0251

IC ID: 7908

Information Collection (IC) Details

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Application for Hospital Insurance and Supporting Regulations in 42 CFR 406.6, 406.7,406.10,406.11 and 406.20
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 406.6 42 CFR 406.7 42 CFR 406.10 42 CFR 406.11 42 CFR 406.20

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-18F5-SP SOLICITUD PARA EL SEGURO DE HOSPITAL CMS-18F5.pdf Yes Yes Paper Only
Form and Instruction CMS-18F5 APPLICATION FOR HOSPITAL INSURANCE CMS18F5.pdf Yes Yes Paper Only

Health Health Care Services

 

50,000 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 50,000 0 0 0 0 50,000
Annual IC Time Burden (Hours) 12,495 0 0 -5 0 12,500
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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