Information Collection

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

IC 7908 under ICR 200708-0938-006 · OMB 0938-0251.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.