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

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

OMB: 0938-0245

IC ID: 7901

Information Collection (IC) Details

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Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 407.11 42 CFR 407.10 42 CFR 408.40

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-4040SP Petici?n Para Inscribirse En El Seguro Medico Suplementario CMS-4040SP.pdf Yes Yes Fillable Printable
Form and Instruction CMS-4040 Request for Enrollment in Supplementary Medical Insurance CMS-4040.pdf Yes Yes Fillable Printable

Health Health Care Services

 

10,000 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 10,000 0 0 0 10,000 0
Annual IC Time Burden (Hours) 2,500 0 0 0 2,500 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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