Application for Health Coverage and Help Paying Costs Short Form

Data Collection to Support Eligibility Determinations for Insurance Affordability Programs and Enrollment through Health Benefits Exchanges, Medicaid and Children's Health Insurance Program Agencies

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CMS-10440 Application for Health Coverage and Help Paying Costs Short Form Form and Instruction
CMS-10440 CMS-10440.Attachment B-Application for Health Coverage & CMS-10440.AttachmentB-Application for Health Coverage & Help Paying Costs (Short Form).pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Application for Health Coverage and Help Paying Costs Short Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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-10440	CMS-10440.Attachment B-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: 532,800	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	532,800	274,064	258,736
Annual IC Time Burden (Hours)	266,400	244,839	21,561
Annual IC Cost Burden (Dollars)	0	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.