Information Collection

Application for Health Coverage and Help Paying Costs Short Form

IC 206713 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⚠️ Notice: This information collection may be referencing outdated material.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 Application for Health Coverage and Help Paying Costs Short Form	Form and Instruction
CMS-10440 CMS-10440.AttachmentB-Application for Health Coverage & CMS-10440.AttachmentB-Application for Health Coverage & Help Paying Costs (Short Form).pdf	Form and Instruction

IC Title:

Application for Health Coverage and Help Paying Costs Short Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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-10440	CMS-10440.AttachmentB-Application for Health Coverage & Help Paying Costs (Short Form)	CMS-10440.AttachmentB-Application for Health Coverage & Help Paying Costs (Short Form).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 258,736

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	Program Change Due to New Statute
Annual Number of Responses for this IC	258,736	258,736
Annual IC Time Burden (Hours)	21,561	21,561
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.