Information Collection

Application for Enrollment in Medicare Part B (Medical Insurance)

IC 209928 under ICR 201401-0938-003 · OMB 0938-1230.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1230 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-40B Application for Enrollment in Medicare Part B (Medical Insurance) Form and Instruction
CMS-40B Application for Enrollment In Medicare Part B (Medical I CMS-40B_508_112613.pdf Form and Instruction
CMS-40B (SP) Solicitud De Inscripci?n Para Medicare Parte B (Seguro M CMS-40B_SP_508_120413.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application for Enrollment in Medicare Part B (Medical Insurance)	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-40B	Application for Enrollment In Medicare Part B (Medical Insurance)	CMS-40B_508_112613.pdf		Yes	No	Fillable Printable
Form and Instruction	CMS-40B (SP)	Solicitud De Inscripci?n Para Medicare Parte B (Seguro M?dico)	CMS-40B_SP_508_120413.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	200,000	200,000
Annual IC Time Burden (Hours)	50,000	50,000
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.