Application for Hospital Insurance Benefits Medicare for Individuals with End Stage Renal Disease and Supporting Regulations in 42 CFR 406.7 and 406.13

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0080 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-43 Application for Hospital Insurance Benefits Medicare for Individuals with End Stage Renal Disease and Supporting Regulations in 42 CFR 406.7 and 406.13 Form
CMS-43 ApplicAtion for HospitAl InsurAnce Benefits for Individu CMS-43-508.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application for Hospital Insurance Benefits Medicare for Individuals with End Stage Renal Disease and Supporting Regulations in 42 CFR 406.7 and 406.13	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 406.7 42 CFR 406.13

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-43	ApplicAtion for HospitAl InsurAnce Benefits for Individuals with End Stage Renal Disease	CMS-43-508.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 60,000	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	60,000	60,000
Annual IC Time Burden (Hours)	25,990	25,990
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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