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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0251 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-18F5-SP Application for Hospital Insurance and Supporting Regulations in 42 CFR 406.6, 406.7,406.10,406.11 and 406.20 Form and Instruction
CMS-18F5-SP SOLICITUD PARA EL SEGURO DE HOSPITAL CMS-18F5.pdf Form and Instruction
CMS-18F5 APPLICATION FOR HOSPITAL INSURANCE CMS18F5.pdf Form and Instruction

Information Collection (IC) Details

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

Information Collection Instruments:

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

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

Documents for IC

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.