Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0245 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-4040SP Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40 Form and Instruction
CMS-4040 Request for Enrollment in Supplementary Medical Insuranc CMS-4040-6-11-2009.pdf Form and Instruction
CMS-4040SP Peticion para inscribirse en el seguro medico suplementa CMS-4040SP-6-11-2009.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40	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 42 CFR 408.40

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-4040SP	Peticion para inscribirse en el seguro medico suplementario	CMS-4040SP-6-11-2009.pdf		Yes	Yes	Paper Only
Form and Instruction	CMS-4040	Request for Enrollment in Supplementary Medical Insurance	CMS-4040-6-11-2009.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 %

	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

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.