Information Collection

Individual Application

IC 205692 under ICR 201302-0938-004 · OMB 0938-1191.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1191 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10440 Individual Application	Form and Instruction
CMS-10440 CMS-10440_AttachmentA-Individual Online Application Ques CMS-10440.AttachmentA-Individual Online Application Questionnaire.pdf	Form and Instruction
CMS-10440 AttachmentC-Application for Health Coverage & Help Payin CMS-10440.AttachmentC-Application for Health Coverage & Help Paying Costs.pdf	Form and Instruction
CMS-10440 CMS_10440_AttachmentD-Application for Health Coverage CMS-10440.AttachmentD-Application for Health Coverage.pdf	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Individual Application

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR Parts 155, 156, 157 42 CFR Parts 431, 435, 457 26 CFR 1 and 602 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10440	AttachmentC-Application for Health Coverage & Help Paying Costs	CMS-10440.AttachmentC-Application for Health Coverage & Help Paying Costs.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10440	CMS-10440_AttachmentA-Individual Online Application Questionnaire	CMS-10440.AttachmentA-Individual Online Application Questionnaire.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10440	CMS_10440_AttachmentD-Application for Health Coverage	CMS-10440.AttachmentD-Application for Health Coverage.pdf	Yes	No	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,776,698

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	2,776,698	2,776,698
Annual IC Time Burden (Hours)	1,407,261	1,407,261
Annual IC Cost Burden (Dollars)	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.