Application for Enrollment in Medicare Part B (Medical Insurance)

Application for Enrollment in Medicare - The Medical Insurance Program (CMS-40B)

⚠️ Notice: This information collection may be referencing outdated material.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 2017.pdf www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS40B-E.pdf Form and Instruction
CMS-40B (SP) Solicitud De Inscripci?n Para Medicare Parte B (Seguro M CMS-40B_SP_508 2017.pdf www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS40B-S.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Application for Enrollment in Medicare Part B (Medical Insurance)	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-40B	Application for Enrollment In Medicare Part B (Medical Insurance)	CMS-40B_508 2017.pdf	https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS40B-E.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 2017.pdf	https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS40B-S.pdf	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 400,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	400,000	200,000	200,000
Annual IC Time Burden (Hours)	100,000	50,000	50,000
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.